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 HEART DISEASE & TREATMENT

CARDIOVASCULAR SURGERY

Carotid Endarterectomy

Carotid arteries, Carotid artery disease and Stroke
Carotid arteries are located on each side of the neck, carrying blood from the heart to supply brain tissue.

Atherosclerotic plaque may developing in the walls of carotid arteries due to aging and other risk factors. The plaque compose of cholesterol, calcium, cells and fibrous tissue. As more plaque builds up, the carotid arteries become narrow and stiffen or hardening. Blood clot can form on the plaque. Piece of plaque material or clot can also break loose and travel to the brain and block the blood flow to certain part of your brain. If a large enough area of the brain is affected it can cause a major stroke, which can cause permanent brain damage, body parts paralysis or death. If a clot or plaque blocks only a tiny artery in the brain, it may cause a transient ischemic attack (TIA), also known as a mini-stroke. A TIA is often a warning sign that a major stroke may occur in the near future, and it should be a signal to seek treatment soon, before a stroke occurs.

What Is Carotid Endarterectomy?
 
Carotid endarterectomy is a type of surgery used to remove plaque from the carotid artery.

During the operation, the surgeon peels the plaque away from the carotid artery.

Once the plaque is removed from the carotid artery, more oxygen-rich blood can flow through the artery to the brain, reducing the risk of stroke.
 
 
Are there any alternatives?
A carotid endarterectomy is the main treatment for narrowing of the carotid arteries, but sometimes an alternative procedure called carotid artery stent placement may be available. This is a less invasive procedure than a carotid endarterectomy. This technique involve passing a thin flexible tube into the carotid artery through a small cut in the groin. A mesh cylinder (stent) is then placed into the narrowed section of artery to widen it and allow blood to flow through it more easily.

In several clinical trials, the 30-day incidence of heart attack, stroke, or death was significantly higher with stenting than with endarterectomy. The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) funded by the National Institutes of Health (NIH) reported that the results of stents and endarterectomy were comparable. However, the European International Carotid Stenting Study (ICSS) found that stents had almost double the rate of complications. The experience and result from each institute of these treatments are varried. Patient should discuss with physician whether which procedure is more suitable to you.

Diagnosing carotid artery disease
Your doctor may suspect that you have carotid artery disease if you have the symptoms of a stroke or TIA, such as the face drooping on one side, numbness or weakness in the arms or legs, speech problems or loss of vision in one eye, either transiently or persistently.
However, occasionally, significant carotid artery disease may be found during part of general examination for other reason. This is called an asymptomatic carotid stenosis.
You should also know that stroke or TIA are not always relate to carotid artery disease.
Carotid artery disease can be diagnosed by:
  • Duplex ultrasound scan – sound waves are used to produce an image of your blood vessels and measure the blood flow through them. An ultrasound scan is usually used first to check if there is any narrowing in your arteries and to determine whether it is severe enough for you to benefit from having surgery. If your arteries are narrowed, you may need to have further tests to confirm the diagnosis, such as a CTA or MRA.                              
  • Computed tomographic angiogram (CTA) – a special dye is injected into a vein and a CT machine is used to take X-rays to build up a picture of your neck arteries.
  • Magnetic resonance angiography (MRA) – a magnetic field and radio waves are used to produce images of your arteries and the blood flow within them.
  • Angiography (or arteriography) – a special dye is injected into arch of aorta or into selected carotid artery for visualization of the carotid artery with X-ray technique.
Who Needs Carotid Endarterectomy?
Your doctor may recommend carotid endarterectomy (CEA) if you have carotid artery disease. CEA can help prevent strokes in people who have this disease.
CEA is most helpful for people who have carotid artery disease and one or more of the following:
  • A prior stroke.
  • A prior transient ischemic attack (TIA), also called a "mini-stroke." During a TIA, you may have some or all of the symptoms of a stroke (face drooping on one side, numbness or weakness in the arms or legs, speech problems or loss of vision in one eye). However, the symptoms usually last less than 1–2 hours (although they may last up to 24 hours).
  • Severely blocked carotid arteries (even if you don't have stroke symptoms).
     
The procedure
The carotid endarterectomy procedure can be carried out using local anesthetic or general anesthetic. Local anesthetic allows your surgeon to monitor the response of your brain to the changes in blood flow during surgery.
During the procedure, a 7 to 10cm (2.5 to 4 inch) incision will be made between the corner of your jaw and your breastbone. A small incision is then made along the narrowed section of artery and the fatty deposits that have built up there are removed.
The artery is then closed with stitches or a patch and your skin is sealed with stitches.
A carotid endarterectomy usually takes one to two hours to perform. If both of your carotid arteries need to be unblocked, two separate procedures will be carried out. One side will be done first and the second side will be done a few weeks later.


What happens after the procedure?
You will usually be moved to the recovery area or intensive care area after a carotid endarterectomy so you can be monitored for one day, then to standard ward. Most people are well enough to go home within about 48 hours of the procedure.
During that time in the hospital, you will need to lie flat and not move your head too much. You may find that your neck aches, and this may last for up to 2 weeks. Try to avoid physically demanding activities for about 1 week. It may take as long as 2 weeks before you are totally healed.
Risks of carotid endarterectomy
As with all types of surgery, there are risks associated with having a carotid endarterectomy.

The major risks are:
  • Stroke is one possible complication following a carotid endarterectomy. This risk is very low, ranging between 1 and 3 percent.
  • Heart attack. Many patients with carotid artery disease also have coronary disease. Your doctor will usually evaluate your heart condition before carotid endarterectomy procedure.
The minor risks are:
There is a small chance of developing other minor complications after having a carotid endarterectomy. These include:
  • Pain or numbness at the wound site – this is temporary and can be treated with painkillers.
  • Bleeding at the site of the wound.
  • Wound infection – the wound where the incision was made can get infected. This affects less than 1% of people and is easily treated with antibiotics.
  • Nerve damage – this can cause a hoarse voice and weakness or numbness on the side of your face. It affects around 4% of people, but is usually temporary and disappears within a month.
  • Narrowing of the carotid artery again – this is called restenosis; further surgery is required in about 2-4% of people.
Your surgeon should explain the risks that are associated with a carotid endarterectomy before you have the procedure. Ask them to clarify anything you're not sure about and answer any concerns you have.
Factors that increase your risk of experiencing complications because of a carotid endarterectomy include:
  • Your age – the risk increases as you get older.
  • Whether you smoke.
  • Having previously had a stroke or transient ischemic attack (TIA) – the risk will depend on the severity of the stroke or TIA, how well you recovered and how recently it occurred.
  • Whether you have a blockage in your other carotid artery as well.
  • Whether you have other health conditions, such as cancer, heart disease, high blood pressure (hypertension) or diabetes.
 
Life after carotid endarterectomy
After a carotid endarterectomy, your doctor may want you to start an exercise program. Other lifestyle changes include quitting smoking, limiting how much alcohol you drink, and controlling your blood pressure and cholesterol levels.

Carotid endarterectomy at Bangkok Heart Hospital
  • Between January 2008 and December 2013, 74 patients underwent carotid endarterectomy at Bangkok Heart Hospital. 59 patients in 2011-2013.
  • Over half of the patients were foreigner (55:45)
  • All patients have lesion >70% stenosis.
  • Symptoms are: Asymptomatic 20.3%, stroke 35.1%, TIAs 13.5%, Amaurosis fugax 9.5%, dizziness 21.6%,
  • 30 days mortality is 0%
  • Stroke at 9 days is 1.3% (1 patient)