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Carotid Artery Disease

Carotid Artery Disease

The carotid arteries run in the front of the neck and supply blood to the brain. Plaque buildup in these arteries is known as carotid artery disease or carotid stenosis. Plaque is usually caused by atherosclerosis or “hardening of the arteries” and when thick enough can narrow the artery and put a person at risk for stroke.

Wide population screening for carotid disease is not felt to be helpful, but if you have one or more of the following risk factors, a physician might consider a carotid ultrasound:

  • High blood pressure
  • High cholesterol
  • Diabetes
  • Arterial disease (heart disease, peripheral artery disease, aortic aneurysm)
  • Smoking and other tobacco use
  • Family history of stroke or early heart disease
  • Personal history of stroke or mini-stroke
  • If your doctor hears a bruit (murmur or rushing sound) on the side of your neck with a stethoscope

Carotid Artery Disease and Stroke

Carotid artery disease causes more than half of strokes in the United States. This occurs when a fragment of plaque or a blood clot forming on the plaque surface travels to the brain and blocks small arteries in the brain. Learn more about symptoms of stroke.

Treating severe carotid stenosis decreases the chances of having a stroke for people who have never had a stroke and also in stroke survivors. The gold standard treatment for carotid stenosis is a surgical operation known as carotid endarterectomy.

Carotid Endarterectomy

Carotid endarterectomy is an operation that was first done in the 1950s and has a proven track record of long-term success in reducing the risk of stroke. It typically takes 1.5 hours and can be done with the patient completely asleep with a breathing tube (general anesthesia) or partially awake with a numbing medicine injected where the incision is made (regional anesthesia). The carotid artery is not far from the surface of the skin. The surgeon makes a small (5-7 cm) incision along the side of the neck and moves the neck muscle aside to show the artery underneath. After temporarily clamping the artery, the surgeon makes a cut through the artery wall. Plaque is removed by scraping the inner lining of the artery with a small spatula. Sometimes a plastic tube (shunt) will be used above and below the area of plaque to allow blood to continue flowing to the brain while the artery is cleaned out. Once the plaque has been removed, the surgeon closes the artery by sewing a small patch to the edges of the artery, making the artery slightly larger than it was at the start. Use of a patch decreases the chance of more plaque build-up to less than five percent over the rest of the patient’s lifetime.

Carotid Stent

Carotid stent is a procedure whose technique is similar to other catheter-based procedures to treat blockages in arteries of the heart, abdomen and legs. A stent is a short tube of thin metal mesh that pushes plaque against the artery wall to make the channel for blood more open. The use of stents in the carotid arteries was first introduced in the late 1980s but only became mainstream in the 2000’s, initially by delivering the stent from the groin artery (transfemoral carotid angioplasty and stent, TF-CAS) and later (in the late 2010s) directly through a small incision at the base of the neck (trans carotid revascularization, TCAR). Early on, carotid stents were done in patients who were either too sick to have carotid endarterectomy, or who had previous neck surgery or radiation making the endarterectomy operation higher risk than normal. Currently, stenting is approved for use in all patients dependent only on appropriate anatomy.

Post-Operative Expectations

Carotid surgery, whether endarterectomy or stent, requires that a patient stay overnight in the hospital so that blood pressure and the incision can be monitored closely. Sometimes blood pressures can be lower or more variable than usual in the first few days after carotid surgery, and blood pressure medications may need to temporarily be adjusted. If a breathing tube was used for the operation (general anesthesia), patients may have a sore throat for a few days. It is also common to have numbness around the incision after surgery; this will go away over a few months. The main risks of carotid surgery include stroke, or mini-stroke (one to three percent nationally), bleeding, nerve injury (less than one percent) and infection (less than five percent).

Once the patient goes home, we recommend:

  • Sleeping with the head and shoulders elevated on two to three pillows for the first few nights
  • No heavy lifting for the first two weeks, and caution with driving, especially if strong pain medications are being used
  • As with any operation that involves an incision, baths and swimming (including hot tubs) should wait two weeks to allow the incisions to heal. Showers are ok.