Carotid
Endarterectomy / Carotid Angioplasty with Stenting
(Endarterectomy-Carotid,
CEA, Carotid Artery Angioplasty with Stenting,
CAS, Carotid Percutaneous Transluminal Angioplasty,
CPTA/Stenting, Carotid Artery Stenting)
What
are carotid endarterectomy and carotid angioplasty
with stenting?
Carotid
endarterectomy (CEA) and carotid artery angioplasty
with stenting (CAS) are procedures performed to
treat carotid artery disease in certain circumstances.
Carotid artery disease, also called carotid artery
stenosis, occurs when the carotid arteries, the
main blood vessels that carry oxygenated blood
to the brain, become narrowed.
Narrowing
of the carotid arteries is most commonly related
to atherosclerosis (a build-up of plaque, which
is a deposit of fatty substances, cholesterol,
cellular waste products, calcium, and fibrin in
the inner lining of an artery). Atherosclerosis,
or "hardening of the arteries," is a vascular
disease (disease of the arteries and veins). Carotid
artery disease is similar to coronary artery disease,
in which blockages occur in the arteries of the
heart, and may cause a heart attack.
It is
unknown exactly how atherosclerosis begins or
what causes it. Atherosclerosis is a slow, progressive,
vascular disease that may start as early as childhood.
However, the disease has the potential to progress
rapidly. It is generally characterized by the
accumulation of fatty deposits along the innermost
layer of the arteries. If the disease process
progresses, plaque formation may take place.
This
thickening narrows the arteries and can decrease
blood flow or completely block the flow of blood
to the brain.
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?
The
main supply of blood to the brain is carried by
the carotid arteries. The carotid arteries branch
off from the aorta (the largest artery in the
body) a short distance from the heart, and extend
upward through the neck carrying oxygen-rich blood
to the brain.
There
are four carotid arteries: the right and left
internal carotid arteries and the right and left
external carotid arteries. One pair (external
and internal) is located on each side of the neck.
Just as a pulse can be felt in the wrists, a pulse
can also be felt on either side of the neck over
the carotid arteries.
Why
are the carotid arteries important?
Because
the carotid arteries deliver blood to the brain,
carotid artery disease can have serious implications
by reducing the flow of oxygen and nutrients to
the brain. The brain needs a constant supply of
oxygen and nutrients in order to function. Even
a brief interruption in blood supply can cause
problems. Brain cells begin to die after just
a few minutes without blood or oxygen. If the
narrowing of the carotid arteries becomes severe
enough to block blood flow, or a piece of atherosclerotic
plaque breaks off and obstructs blood flow to
the brain, a stroke may occur.
Unfortunately,
there may be no symptoms of early carotid artery
disease. An abnormal sound called a bruit (pronounced
brew-ee) may be heard by a stethoscope placed
on the carotid arteries in the neck. A bruit is
an abnormal sound that 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 the disease continues to progress
until sufficient artery blockage exists, problems
may occur, such as a stroke. Because brain tissue
cannot be regenerated (replace itself), stroke
prevention is the goal of treatment.
Surgical
treatment of carotid artery disease:
There
are two procedures used to treat carotid artery
disease. The standard surgical procedure is carotid
endarterectomy (CEA), while the newer minimally
invasive endovascular intervention is called carotid
artery angioplasty with stenting (CAS).
- carotid endarterectomy
In a carotid endarterectomy, atherosclerotic
plaque that has built up on the inside of the
carotid artery wall is surgically removed. An
incision is made on the side of the neck where
the affected carotid artery is located. Under
direct visualization, the artery is opened and
the plaque removed. The artery is sutured back
together, restoring normal blood flow to the
brain. This procedure may be performed while
a patient remains awake under local anesthesia
or while the patient is asleep under general
anesthesia.
- 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 (long hollow tube) is inserted into
the carotid artery to be treated. This catheter
has a tiny balloon at its tip. The balloon is
inflated once the catheter has been placed into
the narrowed area of the carotid artery. The
inflation of the balloon compresses the fatty
tissue in the artery and makes a larger opening
inside the artery for improved blood flow. A
stent (a tiny, expandable metal coil) may be
inserted into the newly-opened area of the artery
to help keep the artery from narrowing or closing
again.
Because of the potential for clots (emboli)
to dislodge from the plaque into the circulation
of the brain and possibly cause a stroke, there
are now devices called embolic prevention devices
(EPD) being used during CAS. One type of EPD
has a filter-like basket attached to a catheter
that is positioned in the artery so as to "catch"
any clots or small debris that might break loose
from the plaque during the procedure. This technique
may help reduce the incidence of stroke during
carotid angioplasty.
Your
physician will determine the most appropriate
intervention for treating your carotid artery
disease.
Other
related procedures that may be used to diagnose
carotid artery disease include carotid artery
duplex scan and cerebral arteriogram. Please see
these procedures for additional information.
Carotid
endarterectomy may be performed to treat a blockage
or narrowing of the carotid arteries, thus improving
blood supply to the brain. Carotid endarterectomy
has been shown to be effective for preventing
stroke in carotid artery disease.
Carotid
artery angioplasty with stenting (CAS) is a procedure
currently being used on selected patients who
are at high risk for surgery. While this procedure
is performed widely, the long-term effects are
still being studied.
High
risk conditions under which CAS may be considered
include, but are not limited to, the following:
- older age
- coronary artery disease
or pending open heart surgery
- heart failure
- heart valve disease
- heart arrhythmias
- angina or heart attack
within the last 6 months
- cancer
- carotid artery disease
in more than one carotid artery
- location of the blockage
in the carotid artery
- carotid artery stenosis
(narrowing) caused by radiation, previous surgery
on the neck, or severe chronic obstructive pulmonary
disease (COPD)
Carotid
artery disease may be asymptomatic (without symptoms)
or symptomatic (with symptoms). Asymptomatic carotid
disease is the presence of a significant amount
of atherosclerotic plaque build-up in the carotid
arteries without obstructing blood flow enough
to cause symptoms. Symptomatic carotid artery
disease may result in either a transient ischemic
attack (TIA) and/or a stroke (brain attack).
The
decision to treat carotid artery disease is based
on certain criteria such as, but not limited to,
the following:
- Symptomatic and asymptomatic
carotid artery disease with blockage greater
than 70 percent in the internal carotid artery
is usually treated surgically.
- Asymptomatic and symptomatic
carotid artery disease with blockage of 50 percent
to 69 percent (with results from diagnostic
tests indicating blockage closer to 69 percent)
may require surgical treatment. Risk factors
associated with carotid artery disease are taken
under consideration when determining the need
for surgery.
- Asymptomatic and symptomatic
carotid artery disease with blockage of 50 percent
to 69 percent (and results of diagnostic tests
indicating blockage closer to 50 percent) may
be treated medically, depending on the individual
situation.
- Asymptomatic and symptomatic
carotid artery disease with blockage of less
than 50 percent are generally treated medically.
Choice
of treatment such as carotid endarterectomy, carotid
artery angioplasty with stenting, or medical treatment
will be determined by your physician.
There
may be other reasons for your physician to recommend
a carotid endarterectomy or carotid artery angioplasty
with stenting.
As with
any surgical procedure, complications can occur.
Some possible complications of both carotid endarterectomy
and carotid angioplasty with stenting may include,
but are not limited to, the following:
- stroke or transient
ischemic attack (TIA)
- heart attack (myocardial
infarction)
- wound hematoma (pooling
of blood into surrounding tissue causing swelling)
- cranial nerve deficits
(problems with certain functions of the eyes,
nose, tongue, and/or ears that 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
- hypertension (high
blood pressure)
- arrhythmias (irregular
heart beat)
- airway obstruction
from swelling
- stent ingrowth (overgrowth
of tissue where the stent is placed which may
cause a blockage) in CAS procedures
The
amount of radiation used with fluoroscopy during
a CAS procedure is considered minimal; therefore,
the risk for radiation exposure is very low.
There
is a risk for allergic reaction to the dye used
in a CAS procedure. Patients who are allergic
to or sensitive to medications, contrast dye,
iodine, shellfish, or latex should notify their
physician. Also, patients with kidney failure
or other kidney problems should notify their physician.
There
may be other risks depending upon your specific
medical condition. Be sure to discuss any concerns
with your physician prior to the procedure.
- Your physician will
explain the procedure to you and offer you the
opportunity to ask any questions that you might
have about the procedure.
- You will be asked to
sign a consent form that gives your permission
to do the procedure. Read the form carefully
and ask questions if something is not clear.
- In addition to a complete
medical history, your physician may perform
a complete physical examination to ensure you
are in good health before undergoing the procedure.
You may undergo blood tests or other diagnostic
tests.
- Notify your physician
if you are sensitive to or are allergic to any
medications, iodine, latex, tape, contrast dye,
or anesthetic agents (local and general).
- Notify your physician
of all medications (prescription and over-the-counter)
and herbal supplements that you are taking.
- Notify your physician
if you have a history of bleeding disorders
or if you are taking any anticoagulant (blood-thinning)
medications, aspirin, or other medications that
affect blood clotting. It may be necessary for
you to stop some of these medications prior
to the procedure.
- If you are pregnant
or suspect that you are pregnant, you should
notify your physician.
- You will be asked to
fast for eight hours before the procedure, generally
after midnight.
- Your physician may
request a blood test prior to the procedure
to determine how long it takes your blood to
clot.
- You may receive a sedative
prior to the procedure to help you relax.
- Notify your physician
if you have a pacemaker.
- The area around the
surgical site may be shaved.
- If you smoke, you should
stop smoking as soon as possible prior to the
procedure. This may improve your chances for
a successful recovery from surgery and benefit
your overall health status, as smoking increases
clot formation in the blood.
- If your physician determines
that carotid artery angioplasty with stenting
is the appropriate treatment for your carotid
artery disease, you may be started on medication
to help prevent more blockage in the carotid
arteries such as aspirin and clopidogrel (Plavix®)
before the procedure.
- Based upon your medical
condition, your physician may request other
specific preparation.
Both
carotid endarterectomy and carotid angioplasty
with stenting require a stay in hospital. Procedures
may vary depending on your condition and your
physician's practices.
Carotid
endarterectomy:
Generally,
carotid endarterectomy (CEA) follows this process:
- You will be asked to
remove any jewelry or other objects that may
interfere with the procedure.
- You will be asked to
remove your clothing and will be given a gown
to wear.
- You will be asked to
empty your bladder prior to the
procedure.
- An intravenous (IV)
line will be started in your arm or hand. An
additional catheter will be inserted in your
wrist to monitor your blood pressure, as well
as for obtaining blood samples. One or more
additional catheters may be inserted into your
neck, opposite the surgery site, to monitor
your heart function. Alternate sites for the
additional catheter include the subclavian (under
the collarbone) area and the groin.
- You will be positioned
on the operating table, lying on your back,
with your head raised slightly and turned away
from the side to be operated on.
- A catheter will be
inserted into your bladder to drain urine.
- The anesthesiologist
will continuously monitor your heart rate, blood
pressure, breathing, and blood oxygen level
during the surgery.
- CEA may be performed
under local anesthesia. You will be sleepy,
but will not feel the area being operated on.
You will receive a sedative medication in your
IV before the procedure to help you relax. However,
you will remain awake, but sleepy, during the
procedure. This allows the physician to monitor
how you are doing during the procedure by asking
you questions and testing your hand grip strength.
- If the CEA is performed
under local anesthesia, the physician will provide
constant support and keep you comfortable during
the procedure. Pain medicine will be administered.
- Under local anesthesia,
you will receive oxygen through a nasal cannula,
a tube that fits in your nose.
- A CEA may also be performed
under general anesthesia (you will be asleep).
Once you are sedated, a breathing tube will
be inserted through your throat into your lungs.
You will be connected to a ventilator, which
will breathe for you during the procedure.
- You will be given a
dose of antibiotics through your IV to help
prevent infection.
- The skin over the surgical
site will be cleansed with an antiseptic solution.
- The physician will
make an incision (cut) down the side of the
neck over the diseased artery. Once the carotid
artery is exposed, the physician will make an
incision into the artery.
- The physician may use
a device called a shunt to divert blood flow
around the surgical area to maintain blood flow
to the brain. A shunt is a small tube that is
inserted into the carotid artery to deliver
blood flow around the area being operated on.
- With the blood flow
diverted, the physician will remove the atherosclerotic
plaque from the artery.
- The shunt will be removed
and the artery will be closed. The incision
in the neck will be sutured together.
- A drain may be placed
in your neck. The drain is a small tube that
is inserted in the neck area to drain any accumulation
of blood into a small palm-size suction bulb.
It is generally removed the morning after the
procedure.
- You may receive blood
pressure medication through your IV during and
after the procedure to keep your blood pressure
within a certain range.
- If you received general
anesthesia, the physician will wake you up in
the operating room to be sure you can respond
to questions.
- A sterile bandage/dressing
will be applied.
Carotid
angioplasty with stenting (CAS):
Generally,
a CAS procedure follows this process:
- You will be asked to
remove any jewelry or other objects
that may interfere with the procedure.
- You will be asked to
remove your clothing and will be given a gown
to wear.
- You will be asked to
empty your bladder prior to the procedure.
- An intravenous (IV)
line will be started in your arm or hand. An
additional catheter will be inserted in your
wrist to monitor your blood pressure, as well
as for obtaining blood samples. One or more
additional catheters may be inserted into your
neck to monitor your heart function. Alternate
sites for any additional catheters include the
subclavian (under the collarbone) area and the
groin.
- You will be placed
in a supine (on your back) position on the operating
table or on a procedure table in a radiology
suite.
- The anesthesiologist
will continuously monitor your heart rate, blood
pressure, breathing, and blood oxygen level
during the surgery. The groin area (or arm)
will be cleaned with antiseptic soap.
- CAS is usually performed
under local anesthesia. You will not feel the
area being operated on. You will receive a sedative
medication in your IV before the procedure to
help you relax. However, you will likely remain
awake, but sleepy, during the procedure.
- The insertion area
in the groin will be covered with sterile towels
and a sheet.
- A numbing medication
(lidocaine or xylocaine) will be injected into
the skin over the groin area. You may feel some
stinging at the site for a few seconds after
the numbing medication has been injected.
- Once the numbing medication
has taken effect, a sheath, or introducer, will
be inserted into the blood vessel. A sheath
is a plastic tube through which the catheter
will be inserted into the blood vessel and advanced
to the carotid artery. If the arm is used, a
small incision (cut) will be made in the inner
elbow area to expose the blood vessel for insertion
of the sheath.
- It will be very important
for you to remain still during the procedure
so that the catheter placement is not disturbed
and to prevent damage to the groin (or arm)
at the insertion site.
- The angioplasty catheter
will be inserted through the sheath into the
blood vessel. The physician will advance the
catheter through the blood vessel into the carotid
artery. A special type of x-ray, called fluoroscopy
(like an x-ray "movie"), may be used to verify
the location of the catheter inside the body.
- The catheter will be
advanced up towards the heart and the carotid
arteries. Once the catheter is in place, dye
will be injected through the catheter in order
to see the narrowed area(s). You may feel a
brief sensation of warmness just after the dye
is injected, but this sensation is temporary
and will soon pass.
- The physician will
observe the carotid arteries after the x-ray
dye injection on a monitor. X-ray pictures will
be taken.
- In order to protect
the brain from pieces of plaque that may break
off and travel to the brain, a device called
an emboli prevention device (EPD), or cerebral
protection device, will be used. One type of
EPD has a filter-like basket attached to a catheter
that is positioned in the artery so as to "catch"
any clots or small debris that should break
loose from the plaque during the procedure.
- After the narrowed
portion of the artery is located, the angioplasty
catheter will be advanced to that location and
the balloon will be inflated to open the artery.
- A stent may be placed
in order to keep the artery open. A stent is
a tiny, cylinder-like tube made of thin metal
mesh framework. The stent will be in a collapsed
position until after it is inserted, advanced
up into the aorta, and placed in the carotid
artery. The stent will expand (in a spring-like
fashion), attaching to the wall of the carotid
artery.
- Another x-ray picture
will be taken to verify the position of the
stent.
- The angioplasty catheter
will be removed. However, the sheath may be
left in for several more hours. Alternatively,
the physician may remove the entire catheter
system and place a special device called a vascular
closure device at the catheter insertion site.
This device helps to prevent bleeding at the
insertion site.
- You will be assisted
to slide from the table onto a stretcher so
that you can be taken to the recovery area.
In
the hospital - carotid endarterectomy:
After
the procedure you will be taken 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.
At the
appropriate time, you will be assisted out of
bed to walk around as tolerated.
If a
drainage tube was placed in the incision during
the procedure, it most likely will be removed
the next morning by your physician.
Your
diet will be advanced to solid foods as tolerated.
Take
a pain reliever for soreness as recommended by
your physician. Aspirin or certain other pain
medications may increase the chance of bleeding.
Be sure to take only recommended medications.
Your
physician may schedule you for follow-up duplex
ultrasound procedures to monitor the carotid arteries
in your neck for a period of time.
Generally,
patients are able to go home within one to two
days following a carotid endarterectomy.
In
the hospital - carotid angioplasty with stenting:
After
the procedure you will be taken 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:
You will not be allowed to bend your leg nearest
the insertion site, if the insertion was done
in the groin, for several hours. To help you remember
to keep your leg straight, the knee of the affected
leg may be covered with a sheet and the ends tucked
under the mattress on both sides of the bed to
form a type of loose restraint.
A nurse
will monitor your vital signs, your neurological
signs, and the injection site while you are in
the recovery room.
You
may be given pain medication for pain or discomfort
related to the injection site or having to lie
flat and still for a prolonged period.
If the
sheath was left in the insertion site, it will
be removed from the groin or arm at the appropriate
time. After the sheath is removed, pressure will
be applied directly on the site either manually
or with a clamp-type device for about 20 minutes.
After bleeding has stopped completely with the
pressure application, a tight dressing will be
applied on the site. You will continue to lie
in bed for a specified period, at least two hours
or longer. It is very important that you keep
your leg or arm with the catheter site straight
during this period.
After
the specified period of bed rest has been completed,
you may get out of bed. The nurse will assist
you the first time you get up, and will check
your blood pressure while you are lying, sitting,
and standing.
You
may be discharged from the hospital the next day
depending on your progress.
At
home - carotid endarterectomy:
Once
you are home, it is important to keep the incision
area clean and dry. Your physician will give you
specific bathing instructions. If stitches are
used, they will be removed during a follow-up
office visit. If adhesive strips are used, they
should be kept dry, and generally will fall off
within a few days.
You
may resume your normal diet unless your physician
advises you differently.
Notify
your physician to report any of the following:
- fever and/or chills
- redness, swelling,
or bleeding or other drainage from the incision
site
- increased pain around
the incision site
Your
physician may give you additional or alternate
instructions after the procedure, depending on
your particular situation.
At
home - carotid angioplasty with stenting:
Once
at home, you should monitor the injection site
for bleeding. A small bruise is normal, as is
an occasional drop of blood at the site.
If the
groin or arm was used, you should monitor the
leg or arm for changes in temperature or color,
pain, numbness, tingling, or loss of function
of the limb.
You
may be advised not to do any strenuous activities
or take a hot bath or shower for a period of time
after the procedure.
Your
physician may want to schedule you for follow-up
duplex ultrasound, magnetic resonance imaging
(MRI), or computed tomography (CT) scans to monitor
the carotid arteries in your neck for a prescribed
period of time.
MRI
is a diagnostic procedure used for many different
conditions. Because of the magnet used in the
MRI machine, the presence of metal in or on a
patient can affect the quality of the test. If
you receive a stent, you may still undergo MRI
without damage to your stent. Your physician will
most likely suggest that you not undergo an MRI
for a month or so after your procedure unless
there is an emergency situation.
Notify
your physician to report any of the following:
- fever and/or chills
- increased pain, redness,
swelling, or bleeding or other drainage
from the groin injection site
- coolness, numbness
and/or tingling or other changes in the affected
extremity
Your
physician may give you additional or alternate
instructions after the procedure, depending on
your particular situation.
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.
This
page contains links to other Web sites with information
about this procedure and related health conditions.
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