Carotid Disease

What are my carotids and what is carotid disease?

The carotid arteries are a pair of blood vessels that run in the neck.  Each person has two carotid arteries, one on either side of the neck. They are two of the four major arteries supplying blood to your brain.

When we talk of carotid disease we mean the "furring-up" of these arteries.  The "fur" in the arteries is properly known as a plaque or atheroma.  The process of "furring-up" of the artery is medically known as atherosclerosis.  This process is accelerated if you smoke, have poorly controlled diabetes or high blood pressure.  The plaques themselves are made up from cholesterol, calcium and fibrous tissue.

As the plaques thicken your arteries become narrower and the artery can even become blocked.  If the artery is blocked it can affect the blood supply to the brain which can cause symptoms of a mini-stroke (TIA) or a stroke.  Even if the artery does not block completely it can cause symptoms.  When the artery becomes narrowed the blood travelling within it moves much faster (think of the water coming out of your garden hose with your finger on the end).  When the blood has to rush through the artery it can disturb some of the plaque and send it up to the brain which can cause a TIA or a stroke.  We measure the degree of narrowing with a type of scan known as a Duplex Ultrasound Scan.

Removing the plaques and widening the artery therefore helps to prevent stroke.  The operation to do this is called a Carotid Endarterectomy and is an effective, safe and long lasting treatment.  The timing of this operation will depend on the extent of disease in your arteries and it is quite common to have patients return for many scans before deciding to do an operation.

 

What is carotid endarterectomy?

Carotid endarterectomy is an operation to remove the plaques (or 'fur') from the carotid artery.  The name comes from the Latin words Endarterium meaning lining of the artery and the suffix -ectomy meaning to remove.  During the operation your surgeon removes the inner lining and the plaques from the carotid artery.

Those eligible for the operation include people who have experienced a mini stroke (TIA), multiple mini-strokes, or stroke.  We sometimes will perform operations on patients who have not had any symptoms from their disease if your surgeon feels the benefits outweigh the risks of the operation.

Your general health is taken into account when deciding whether an operation is in your best interests.  An operation on your carotid arteries will carry a higher risk to you if you have severe heart or lung disease, have had previous stroke, are diabetic, smoke, or have blockages in any of the other arteries to the brain.

 

What are the risks of the surgery?

Carotid endarterectomy is a relatively safe operation, but as with any surgery there are some risks.  The major complication of this operation is stroke, but the risk is very low (between 1% and 3%).  Another complication is that the artery narrows again after the operation - re-stenosis, the risk is still low (between 2% and 3%) but this is much more likely if you continue to smoke.  There are some rarer risks of the surgery including damage to the nerves that lie near the artery.  This damage to the nerve is usually bruising of the nerve that gets better with time, but in very rare cases can be permanent.  Nerve damage can lead to a hoarse voice, difficulty with swallowing or numbing of the face or tongue.

All risks involved with the procedure will be discussed with you in detail when your surgeon discusses your consent form.

 

What will happen when I come into hospital?

If your surgeon decides that the time has come for an operation on your carotid disease you will be asked to come in to a Pre-Op Clinic.  The Pre-Op Clinic is a chance for you to familiarise yourself with the hospital and the ward you will be staying on (A3).  You will usually meet the junior doctor on the team (or House Officer) who will ask you a number of questions about your medical health.  This is an opportunity for us to identify any health or other issues which may need to be addressed during your stay with us.  Some blood tests will also be taken as well as a tracing of your heart (or ECG). 

The next time you come to the hospital will probably be for your operation.  You will be asked to come into the ward the afternoon before the surgery so that final checks can be made before we perform your operation.  In most cases the ultrasound scan of your neck will be repeated before your operation to confirm that there have been no changes since you were seen in the clinic.  In some special circumstances you may require a CT scan, Magnetic Resonance scan or angiography. 

You will be allowed to eat the night before the surgery but are usually asked not to eat anything from midnight until after your operation.  Fasting prior to an operation is very important for your safety.  You will be asked to sign a consent form outlining the risks and benefits of the surgery and your surgeon will answer any remaining questions you may have about the operation.  You will then be taken down to the theatre reception and then on to the anaesthetic room. 

 

How is it done?

In the anaesthetic room the anaesthetist will send you to sleep.  Once you are unconscious they will then inject local anaesthetic (similar to dental anaesthetic) into the skin of the neck.  The surgeon will then shave the operation site to help prevent wound infection.  A cut is made in the neck and the carotid artery is carefully exposed.  A clamp is placed above and below the diseased artery to prevent bleeding.  The artery is then opened exposing the disease.  Some surgeons will put in a shunt (or bypass) at this point to allow blood to flow past the operation site.  If the decision is taken not to use a shunt the blood supply to the brain is carefully monitored throughout the procedure.  The plaque is then carefully removed from the artery and any fragments are meticulously cleaned from the artery wall.  Once the surgeon is happy the artery is carefully closed, often using a small patch of material to make the artery wider and less likely to re-narrow.  The clamps are removed and your neck is carefully sewn back together. A dressing is applied and the operation is complete.

 

What can I expect after the operation?

After the operation, you will be taken to a recovery ward in theatre and closely monitored before returning to the high-observation section of A3 (the vascular ward).  In the high-obs bay you will be closely monitored for at least 24hours.  You will initially receive fluid and nutrients through a drip until you are fit enough to eat and drink.  You will probably only be in hospital for 1-2 days after the operation.

 

When can I resume normal activities?

The sooner you get back to your normal activities the better.  We would however advise against driving or strenuous activity for at least two weeks (please check with your motor insurer that you are covered to drive).  If you have any concerns, or if you have any symptoms suggestive of a stroke, headache or neck swelling after you have gone home you should contact the ward, your GP or A&E immediately.

What else can I do after my operation?

Your risk of stroke is reduced after carotid endarterectomy but the operation does not stop the process of "furring" of the arteries.  To keep your arteries healthy (before and after your operation) you should follow these simple steps: 

• Take exercise - walking is especially helpful
• Eat healthily - eat food low in saturated fat, cholesterol and calories
• Stop smoking
• Make sure your diabetes and blood pressure are well controlled

Thank you for reading this, if you have any further questions about your carotid disease or upcoming operation, please don't be afraid to ask a member of the team.  We hope this has been helpful and answered your questions.