OHSU

Carotid Endarterectomy & Stent

Procedure Overview

What are carotid endarterectomy and carotid angioplasty with stenting? Carotid endarterectomy (CEA) and carotid artery angioplasty with stenting (CAS) are procedures done to treat carotid artery disease in certain circumstances. Carotid artery disease, also called carotid artery stenosis, occurs when the carotid arteries become narrowed. The carotid arteries are important because they are the main blood vessels carrying oxygen-rich blood to your brain. If a carotid artery is blocked, you can have a stroke. The carotid arteries are in your neck.

Narrowing of the carotid arteries is usually caused by atherosclerosis (fatty deposits in blood vessels that make blood clots more likely). Atherosclerosis, or "hardening of the arteries," is a blood vessel disease (disease of the arteries and veins).It can decrease blood flow or completely block the flow of blood to your brain.

It is unknown exactly how atherosclerosis begins or what causes it. Atherosclerosis is a slow, progressive blood vessel disease that may start as early as childhood. However, it can progress rapidly.

To better understand how carotid artery disease affects the brain, a basic review of the anatomy of the circulation system of the brain follows.

 

What are the carotid arteries?

Your carotid arteries are large blood vessels in your neck. They are the main blood supply to your brain. The carotid arteries branch off from the aorta (the largest artery in the body) a short distance from your heart, and extend upward through the neck.

Why are the carotid arteries important?

Because your carotid arteries deliver blood to the brain, carotid artery disease can cause brain damage if it decreases the flow of oxygen and nutrients to the brain. In order to function, your brain needs a constant supply of oxygen and nutrients. Even a short interruption in blood supply can cause serious health problems, because brain cells start to die after just a few minutes without blood or oxygen. If the narrowing of your carotid arteries becomes severe enough to block blood flow, or a piece of the plaque (fatty deposit inside the artery) breaks off and blocks blood flow to the brain, you could have a stroke.

Unfortunately, there may be no symptoms of early carotid artery disease. Your doctor may hear an abnormal sound called a bruit (pronounced brew-ee) by listening to your carotid arteries with a stethoscope. A bruit is produced by blood passing through a narrowed artery. A bruit is generally considered a sign of an atherosclerotic artery; however, an artery may be diseased without producing a bruit. If carotid artery disease gets worse until an artery is blocked, you could have a stroke. Brain tissue cannot replace itself after it dies, so your doctor and Stroke Center healthcare team work to prevent a stroke before it happens.

Surgical treatment of carotid artery disease

There are two procedures used to treat carotid artery disease. The standard surgical procedure is carotid endarterectomy (CEA). The newer, minimally invasive procedure is called carotid artery angioplasty with stenting (CAS).

  • Carotid endarterectomy
    In a carotid endarterectomy, atherosclerotic plaque (fatty material) that has built up on the inside of your carotid artery wall is surgically removed. Your doctor makes an incision (cut) on the side of the neck where the affected carotid artery is located. The artery is opened and the plaque is removed. Your doctor sews the artery back together, restoring normal blood flow to the brain. This procedure can be done with local anesthesia (numbing medicine) and sedation (medication to help you relax and minimize discomfort). It can also be done with general anesthesia (you're asleep and don't remember the procedure when you wake up).
  • Carotid artery angioplasty with stenting (CAS)
    Carotid artery angioplasty with stenting (CAS) is a minimally invasive procedure requiring only a small incision in the groin. A special catheter (thin, hollow tube) is inserted into the carotid artery to be treated. This catheter has a tiny balloon at its tip. When the catheter is the narrowed area of your artery, your doctor blows up the balloon. The balloon compresses the fat deposits in your artery and makes a larger opening inside the artery. This improves blood flow. During the procedure, your doctor might put a stent (a tiny, expandable metal coil) in the opened part of the artery to help keep it from narrowing or closing again.

    The CAS procedure can cause pieces of plaque (fatty material) to break off from your artery and travel to your brain. This can cause a stroke. Your doctor might use a small device called an embolic protection device (EPD) to help prevent this. One type of EPD has a filter-like basket attached to a catheter. During your procedure, the basket is placed to catch any clots or small pieces of tissue that might break loose from the plaque.

Your OHSU Stroke Center doctor will decide on the best treatment option for your carotid artery disease.

Reasons for the Procedure

Your doctor might do a carotid endarterectomy to treat a blockage or narrowing of your carotid arteries. This can improve blood supply to the brain. Carotid endarterectomy has been shown to be effective for preventing stroke in people with carotid artery disease.

Carotid artery angioplasty with stenting (CAS) is a procedure for people who have a high risk of serious side effects with surgery. Many doctors do this procedure, but its long-term effects are still being studied.

Your OHSU Stroke Center doctor might consider doing a CAS procedure if your age could make surgery less safe or you have any of the following conditions:

  • Coronary artery disease, or are scheduled to have open heart surgery
  • Heart failure
  • Heart valve disease
  • Heart arrhythmias (abnormal heart rhythm)
  • Angina or heart attack in the last six months
  • Cancer Carotid artery disease in more than one carotid artery
  • Carotid artery blockage in a place where doctors can't safely remove it with surgery
  • Carotid artery stenosis (narrowing) caused by radiation, previous neck surgery or severe chronic obstructive pulmonary disease (COPD)

Carotid artery disease can be asymptomatic (no symptoms) or symptomatic (you have symptoms). Asymptomatic carotid disease means you have more than a small amount of atherosclerotic plaque (fatty material) in your carotid arteries, but it doesn't block blood flow enough to cause symptoms. If you do have symptoms, they can be very serious. Symptomatic carotid artery disease can cause a transient ischemic attack (TIA, also called a "mini-stroke), a stroke (brain attack) or both.

Your OHSU Stroke Center team decides on treatment for your carotid artery disease based on how much of your artery is blocked. If you have:

  • More than 70 percent of your carotid artery blocked: you usually have surgery.
  • About 50 to 69 percent of your artery is blocked, or closer to 69 percent: you might have surgery or another treatment. If your blockage is closer to 50 percent, you might take medication instead of having surgery or another procedure.
  • Less than 50 percent of your artery is blocked: you usually take medication.

Your doctor decides which treatment is right for you based on your medical history, general health and other factors.

Risks of the Procedure

Possible risks of carotid endarterectomy and carotid angioplasty with stenting (CAS) include:

  • Stroke or transient ischemic attack (TIA)
  • Heart attack
  • Wound hematoma (swelling caused by blood collecting in nearby tissue)
  • Cranial nerve deficits (problems with certain functions of the eyes, nose, tongue, ears or all of these areas, which are controlled by one or more of the 12 cranial nerves)
  • Intracerebral hemorrhage (bleeding into the brain)
  • Seizures (bursts of abnormal electrical signals that temporarily interrupt normal electrical brain function) -- an uncommon complication
  • Repeated blockage of the carotid artery
  • Bleeding
  • Infection
  • High blood pressure
  • Irregular heartbeat
  • Breathing blockage caused by swelling
  • Stent ingrowth (tissue growing over the stent used in CAS, which can also block your carotid artery)

Your healthcare team uses X-ray technology to guide the medical equipment used in these procedures. For this reason, you may want to ask your doctor how much radiation is used and if this puts you at risk. It is a good idea to keep a record of your radiation exposure from all the imaging scans you have had, including CT scans, MRI scans and other types of X-rays. Tell your doctor how many scans you have already had. Your risk of disease caused by radiation exposure can go up over time, based on how many imaging scans you have and the type of scan.

There is a risk for allergic reaction to the dye used in a CAS procedure. If you are allergic or sensitive to medications, contrast dye, iodine or latex, please tell your doctor. Also, tell your doctor if you have kidney failure or other kidney problems.

Depending on your medical condition, you might have other risks. If you have any questions or concerns, please talk with your doctor before the procedure.

Before the Procedure

Your doctor explains the coiling procedure to you, and you can ask any questions you have. We ask you to sign a consent form giving us permission to do the procedure. Please read the form carefully and ask a member of your healthcare team if you don't understand something.

Tell a member of your healthcare team if you have ever had a reaction to any contrast dye or are allergic to:

  • Iodine
  • Any medications
  • Latex
  • Tape
  • Any anesthesia (local or general)

Before the procedure, you need to fast (go without eating or drinking) for eight hours. This usually means you should not eat or drink after midnight the day before your procedure. Your doctor can give you exact instructions.

If you are pregnant or think you may be pregnant, tell your doctor. Tell your doctor about all medications you are taking, including prescription and over-the-counter (non-prescription) medications and any herbal supplements or vitamins. Also, tell your doctor if you have a history of bleeding disorders or are taking any anticoagulant (blood-thinning) medications, aspirin or other medications that affect blood clotting. You may need to stop these medications before the procedure. Your doctor may do a blood test before the procedure to determine how long it takes your blood to clot. You might also have other blood tests.

If you have a pacemaker, tell your doctor before the procedure.

If you smoke, you should stop smoking as long as possible before the procedure. This may improve your chances for a successful recovery from surgery. It will also improve your general health, because smoking makes your blood more likely to form clots that could cause a stroke.

If your doctor decides that carotid artery angioplasty with stenting (CAS) is the best treatment for you, he or she might prescribe medication before your procedure such as aspirin or clopidogrel (Plavix). These medications can help prevent more blockage in your carotid arteries.

Based upon your medical condition, your doctor may ask you to do other things to get ready for your procedure.

During the Procedure

Both carotid endarterectomy and carotid angioplasty with stenting (CAS) require a stay in the hospital. How long you stay in the hospital depends on several factors, including:

  • Your brain or stroke condition
  • Your general health
  • How you respond to the procedure
  • Your doctor's decisions about your condition and treatment
  • Other factors

Carotid endarterectomy:

 

Generally, a carotid endarterectomy (CEA) follows this process:

  1. Your healthcare team asks you to take off any jewelry or other objects that may interfere with the procedure. We also ask you to take off your regular clothing and give you a hospital gown to wear. Someone on your healthcare team reminds you to empty your bladder (use the bathroom) before the procedure.
  2. An intravenous (IV) line is placed in your arm or hand. You receive medication through the IV during the procedure, including antibiotics to prevent infection. You might also have blood pressure medication through the IV. This helps keep your blood pressure normal during the procedure.
  3. A catheter (thin, hollow tube) is placed in your wrist to track your blood pressure. Your healthcare team can also take blood samples through this tube. You might have one or more additional catheters in your neck on the opposite side from where your doctor does surgery. These help track your heart function. These other catheters could also be placed under your collarbone or in your groin (upper leg area). You have a catheter in your bladder to drain urine.
  4. During the procedure, the anesthesiologist (doctor specializing in anesthesia) keeps track of your heart rate, blood pressure, breathing and the amount of oxygen in your blood. You may have carotid endarterectomy (CEA) with local anesthesia and sedation (numbing medicine and medicine to make you relax and minimize d discomfort). You are awake during the procedure, so your doctor can ask you questions and test your hand grip strength to see how well you are doing.
  5. If you have local anesthesia, your doctor will provide constant support and keep you comfortable during the procedure. You have pain medicine to keep you from feeling any pain or discomfort. You also get oxygen through a tube in your nose. You may also have CEA with general anesthesia (you're asleep and don't remember the procedure when you wake up). Once you are asleep, a breathing tube is placed through your throat into your lungs. You are connected to a ventilator, a machine that breathes for you during the procedure.
  6. You lie on your back on the operating table. Your head is raised slightly and turned away from the side of the procedure. The skin in the procedure area is cleaned with an antiseptic solution. Your doctor makes an incision (cut) down the side of the neck and into the artery. Before removing the atherosclerotic plaque (fatty material) from your artery, the doctor may use a small tube called a shunt to send blood flow in a different direction, away from the surgery area. This helps keep blood flowing to your brain.
  7. Your doctor removes plaque from your artery. The shunt is removed and your artery is sewn back together. Your doctor may place a drain (small tube) in your neck to drain any blood that collects in the surgery area after the procedure. This is usually removed the day after surgery.
  8. If you had general anesthesia, your doctor wakes you up in the operating room to be sure you can answer questions. Your incision is covered with a sterile bandage.


Carotid angioplasty with stenting (CAS)

Generally, a CAS procedure follows this process:

  1. Your healthcare team asks you to take off any jewelry or other objects that may interfere with the procedure. We also ask you to take off your regular clothing and give you a hospital gown to wear during the procedure. Someone on your healthcare team reminds you to empty your bladder (use the bathroom) before the procedure.
  2. An intravenous (IV) line is placed in your arm or hand. You receive medication through the IV during the procedure, including antibiotics to prevent infection. You might also have blood pressure medication through the IV. This helps keep your blood pressure normal during the procedure.
  3. A catheter (thin, hollow tube) is placed in your wrist to track your blood pressure. Your healthcare team can also take blood samples through this tube. You might have one or more additional catheters in your neck on the opposite side from where your doctor does surgery. These help track your heart function. These other catheters could also be placed under your collarbone or in your groin (upper leg area). You have a catheter in your bladder to drain urine.
  4. You lie on your back on an X-ray table or operating table with an intravenous (IV) line in your hand or arm. You are connected to an EKG monitor that records the electrical activity of your heart during the procedure using small, adhesive electrodes. Your vital signs (heart rate, blood pressure and breathing rate) and neurological signs are monitored during the procedure. The surgery area is cleaned with antiseptic and covered with sterile towels and a sheet to prevent infection.
  5. You usually have CAS with local anesthesia (numbing medicine) and sedation (medicine to help you relax and minimize discomfort). You will not feel the area being operated on. During the procedure, you will probably be awake but sleepy.
  6. Your doctor makes a small incision in your groin or arm area and inserts a small tube called a sheath or inserter. This is carefully moved to the blood vessel. It is important for you to lie still during the procedure so your doctor can place the sheath accurately. Lying still also prevents damage to the insertion area (where the sheath is placed in your groin or arm).
  7. Once the sheath is in place in your blood vessel, your doctor places the angioplasty catheter inside it and moves it carefully to the carotid artery. Your healthcare team may use X-rays to guide the catheter.
  8. Once the catheter reaches the affected artery, contrast dye is injected to help your doctor see the narrowed area. You may feel a brief, warm sensation when dye is injected, but this is temporary.
  9. To protect your brain from any plaque that may break off and travel to your brain, your doctor uses an emboli prevention device (EPD).One type of EPD has a filter-like basket attached to a catheter that is positioned in the artery. This can catch clots or small pieces of tissue that break loose during the procedure.
  10. When your doctor sees the narrowed part of your artery, the angioplasty catheter is moved to that area. A small balloon on the tip of the catheter is blown up. This helps open the carotid artery.
  11. Your doctor may put a small medical device in the artery to keep it open. This is a small tube made of thin metal mesh. After the doctor puts it in place, it expands to hold the artery walls apart. Your doctor uses X-rays to make sure the stent is in the right place.
  12. Once the stent is in place, the angioplasty catheter is removed. The sheath may stay in place for several more hours or your doctor may remove it. Another option is to take out the catheter system and place a special device called a vascular closure device where the catheter was inserted in your leg or arm. This device helps prevent bleeding where the catheter was inserted.
  13. Your healthcare team will help you move from the table to a stretcher so you can go to the recovery area.

After the Procedure

In the hospital - carotid endarterectomy

After the procedure, you go to the recovery room for observation. Once your blood pressure, pulse, and breathing are stable and you are alert, you may go to the intensive care unit (ICU) or your hospital room.

At the appropriate time, someone from your healthcare team will help you get out of bed and walk around as much as you are able. If you have a drain (small tube in your neck to drain blood from the surgery area), this is usually taken out the morning after your procedure. You can eat solid foods when you feel ready unless your doctor tells you differently.

You can usually go home from the hospital one or two days after carotid endarterectomy.

You can take pain medication your doctor recommends. Aspirin and some other pain medications can increase your risk of bleeding, so be sure to ask your doctor or other healthcare team member which pain medications are safe.

After the procedure, you might have ultrasound scans of your carotid arteries from time to time.

In the hospital - carotid angioplasty with stenting:

After the procedure, you go to the recovery room for observation. Once your blood pressure, pulse and breathing are stable and you are alert, you may be taken to the intensive care unit (ICU) or your hospital room.

NOTE: If the catheter was placed in your groin, you need to wait several hours before you bend your leg on the side where the catheter was put in. To help you remember to keep your leg straight, the knee of this leg may be covered with a sheet and the ends tucked under your mattress on both sides of the bed. This helps you remember to keep your leg straight.

A nurse keeps track of your vital signs (temperature, heart rate, breathing, blood pressure and pain level), your neurological signs (signs of nervous system activity) and the injection site (area where the catheter was put in) while you are in the recovery room.

You may be given pain medication for pain or discomfort from the procedure or from having to lie flat and still for a long time.

If the sheath was left in the insertion site, your healthcare team will remove it from your groin or arm at the right time. After the sheath is removed, pressure will be applied directly on the site by hand or with a clamp device for about 20 minutes. After bleeding stops completely, a tight bandage is placed on this area. You lie in bed for two more hours or longer. During this time, it is very important to keep your leg or arm straight on the side where the catheter was put in.

After your bed rest is over, you are allowed to get out of bed. A nurse helps you get up the first time. He or she checks your blood pressure while you are lying down, sitting and standing.

Depending on your condition and how you recover, you may go home from the hospital the day after your procedure.

At home - carotid endarterectomy:

Once you are home, it is important to keep the incision area clean and dry. Your doctor gives you specific instructions on when you can shower or take a bath. If you had stitches, they are taken out during an appointment with your doctor. If you had adhesive strips, they should be kept dry. They usually fall off in a few days.

You can eat normally at home unless your doctor tells you differently.

Your doctor will tell you when you can return to work and other normal activities. Immediately after the procedure, you might need to avoid vigorous activity. Ask your doctor or OHSU Stroke Center team member which activities are safe.

Call your doctor if you have:

  • Fever or chills
  • Increased pain, redness, swelling or bleeding or other fluid draining from the insertion site
  • Coolness, numbness or tingling or other changes in the leg or arm used in the procedure

At home - carotid angioplasty with stenting (CAS):

When you get home, you should check the insertion site (where the catheter was placed in your groin or arm) for bleeding. A small bruise or occasional drop of blood is normal.

Check your leg or arm for:

  • Changes in temperature or color
  • Pain
  • Numbness or tingling
  • Loss of function

Your doctor might tell you to avoid vigorous activity or avoid taking hot baths or showers for a certain time after the procedure.

Your doctor may schedule ultrasound, magnetic resonance imaging (MRI) or computed tomography (CT) scans to check the carotid arteries in your neck. You may have these from time to time after the procedure.

Magnetic resonance imaging (MRI) is a procedure used for many different conditions. An MRI machine contains a magnet, so having metal inside your body can affect MRI scans. If you have a stent, which is metal, you can have MRI scans without damaging your stent. Your doctor will probably tell you not to have an MRI for about a month after your CAS procedure, except in an emergency.

Call your doctor if you have:

  • Fever or chills
  • Increased pain, redness, swelling or bleeding or other drainage from the groin injection site
  • Coolness, numbness or tingling or other changes in the arm or leg used in the procedure

Your doctor may give you other instructions, depending on your condition and general health.

Online Resources

The content provided here is for informational purposes only, and was not designed to diagnose or treat a health problem or disease, or replace the professional medical advice you receive from your physician. Please consult your physician with any questions or concerns you may have regarding your condition.

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