Carotid surgery

What is carotid surgery?

Carotid surgery removes fatty deposits called plaque from inside your carotid arteries, the blood vessels in your neck that carry blood to your brain. Clearing this build-up improves blood flow and lowers your risk of having a stroke.

What conditions does it treat?

Carotid surgery treats carotid artery disease, where 1 or both of the arteries in your neck narrow because of a fatty build-up (atherosclerosis). This narrowing raises your risk of a stroke or a transient ischaemic attack (a TIA, sometimes called a mini-stroke), where a small piece of the fatty material breaks off and travels towards your eye or brain.

You, or someone with you, can recognise the warning signs using FAST:

• Face – has it dropped on 1 side? Can they smile?
• Arms – can they raise both arms and keep them there?
• Speech – is their speech slurred or garbled?
• Time – if you see any of these signs, it's time to call 999.

What are the benefits of having carotid surgery?

Carotid surgery reduces your risk of having a stroke by clearing the blockage causing it. If you have surgery within 2 weeks of your symptoms starting, on average 1 stroke is prevented for every 5 people treated.

Research also shows the operation can improve overall survival, not just lower stroke risk, in people with moderate to severe narrowing of the artery.

Are there different types of surgical approaches?

There are 2 main approaches to treating a narrowed carotid artery. Carotid endarterectomy is very effective and is the main treatment offered to most patients.

• carotid endarterectomy: a cut is made in your neck to reach the artery directly and remove the fatty build-up. It can be done under local or general anaesthetic
• carotid artery stenting: a thin tube is guided from your groin up to the narrowed artery using X-rays. A small balloon widens the artery, and a mesh tube (a stent) is left in place to keep it open. This is usually done under local anaesthetic and doesn't involve a cut in your neck

Stenting can be a good option if you're not well enough for a general anaesthetic, or if your artery is difficult to reach surgically. However, the risk of stroke during and shortly after the procedure is slightly higher with stenting, while the long-term reduction in stroke risk is largely the same for both approaches. Your surgeon may also choose between 2 surgical techniques for removing the plaque during an endarterectomy and will use whichever suits your anatomy best.

What happens before the operation?

Before deciding on surgery, you'll have tests such as an ultrasound scan, a CT scan or an MRI scan, to check your carotid arteries and brain in detail. Your care team uses these results, together with your medical history, to assess your risk and discuss the best option with you.

In the run-up to your operation:

• stop smoking if you smoke, as this increases your risk of a chest infection and slows your recovery
• tell your care team about all the medicines, herbal remedies and supplements you take; if you take a blood-thinning medicine such as warfarin, you may need to stop it temporarily, though most people stay on aspirin throughout
• attend a pre-admission clinic around a week before your operation, where you'll have blood tests and blood pressure checks, plus a heart trace (an ECG), and can meet the healthcare team and ask questions
• arrange your journey home and ask someone to help you for the first day or so after you're back

What happens during the procedure?

1. You're given either a general anaesthetic, so you're asleep throughout, or a local anaesthetic, so you're awake but your neck is numbed. Studies comparing the 2 find no difference in outcomes, so the choice comes down to you, your surgeon and your anaesthetist.
2. Your surgeon makes a cut in your neck, usually around 10cm long, at the site of the blockage.
3. They clamp the artery to briefly stop blood flow, then open it along the narrowed section. A temporary tube called a shunt may be used to keep blood flowing to your brain during this step.
4. The inner lining of the artery is removed, along with the fatty plaque that's built up.
5. The artery is closed, usually with a patch of material to help keep it open, and your neck is stitched. A small drain may be left in the wound to remove any leftover blood, and this is usually taken out the next day.

A carotid endarterectomy usually takes 1–2 hours.

What does recovery look like?

After surgery, you'll spend time in a recovery area where your blood pressure, pulse and breathing are monitored. Most people can get up and walk within a few hours, and any neck pain can be managed with painkillers. If you have a small drain in your neck, it's usually removed the next day, and most people go home 1–2 days after surgery, with bruising and swelling that settles within about a week.

At home, some numbness around your jaw or earlobe can last from 6 months up to a year, and your scar will usually fade over a few months. You'll likely be given medicines such as aspirin or a statin to help prevent blood clots and lower your stroke risk, possibly for the rest of your life.

During your recovery:

• Rest and build back up to your normal activities gradually
• Start gentle exercise when you feel able to, avoiding contact sports or strenuous activity for about 6 weeks
• Don't lift heavy objects for at least 6 weeks
• Don't have a bath or shower until your wound is dry; your care team will advise you on this
• Don't smoke, as this slows your recovery and increases your chance of a heart attack or stroke
• Don't drive until your neck is free of pain and you can comfortably look over your shoulder, which usually takes 4–6 weeks

How quickly you return to work can vary from 1–2 weeks for most people to 2–4 weeks. Your own timeline depends on your job and your recovery, so ask your surgeon for advice suited to you. You may also have follow-up ultrasound checks around a month after surgery and then periodically over the following years to check the artery hasn't narrowed again.

What are the risks and complications?

As with any operation, carotid surgery carries some risks. NHS guidance puts the risk of stroke during or shortly after surgery at around 2%, though this may be higher if you've had a stroke before, and there's a less than 1% risk of death, most often linked to a stroke or heart attack.

Common, usually temporary effects include:

• pain, numbness, bruising or swelling around the wound
• a hoarse voice or minor difficulty swallowing, if a nerve near the artery is affected

Less common risks include:

• an infection in the wound, which is usually treated easily with antibiotics
• heavy bleeding under the wound, which may need further surgery
• longer-lasting nerve damage causing numbness or weakness in part of your face; this is uncommon and can occasionally be permanent
• the artery narrowing again over time (restenosis), which may need further treatment
• a heart attack or seizures

Your individual risk depends on things like the severity of your artery narrowing, whether you've had a stroke before, your age, and other health conditions such as heart disease, diabetes or kidney disease. Your surgeon will explain how these apply to you before you decide whether to go ahead.