What are the steps of a carotid endarterectomy procedure?

From the Guidelines

Carotid endarterectomy is a surgical procedure that involves removing plaque buildup from the carotid artery to prevent stroke, and the steps of the procedure include administering anesthesia, making an incision in the neck, locating the carotid artery, temporarily stopping blood flow, removing the plaque, and closing the artery. The procedure typically begins with the patient receiving general or local anesthesia with sedation 1. The surgeon then makes an incision along the front of the neck, locates the carotid artery, and places clamps above and below the blockage to temporarily stop blood flow. A shunt may be inserted to maintain blood flow to the brain during the operation. The surgeon then makes an incision in the artery and carefully removes the plaque buildup from the arterial wall. After removing the plaque, the artery is closed with sutures or a patch graft (using synthetic material or a piece of the patient's own vein) 1. The clamps are removed to restore blood flow, and the neck incision is closed with sutures.

• The procedure typically takes 1-2 hours.
• Patients usually receive antiplatelet medications like aspirin before and after surgery to prevent blood clots 1.
• Recovery involves 1-2 days in the hospital with monitoring for complications such as bleeding, stroke, or nerve injury.
• Most patients can return to normal activities within 3-4 weeks.
• Carotid endarterectomy is preferred over carotid stenting, especially for patients over 70 years old who are otherwise fit for surgery 1.
• The procedure is effective because it directly removes the atherosclerotic plaque that can break loose and cause strokes, addressing the root cause of carotid artery disease. The most recent and highest quality study recommends that carotid endarterectomy should be performed as soon as possible after the onset of symptoms, ideally within 14 days, for patients with symptomatic carotid stenosis 1.

From the Research

Steps of Carotid Endarterectomy

The steps of a carotid endarterectomy procedure can be outlined as follows:

• Division of the internal carotid artery at its base 2
• Slitting the carotid artery until reaching the distal part of the plaque 2
• Endarterectomy of the internal carotid and common carotid-external carotid axis 2
• Reimplantation of the internal carotid into its ostium, enlarged to the new size of the divided carotid artery 2
• Longitudinal arteriotomy and longitudinal endarterectomy, followed by closure of the arteriotomy by direct suture without a patch 3
• Use of a temporary intraluminal shunt in cases where speech disturbances occur following clamping of carotid arteries 3

Key Considerations

Some key considerations during the procedure include:

• The use of regional anesthesia, which can facilitate intraoperative cerebral function monitoring and reduce the risk of postoperative hypertension and perioperative myocardial infarction 4
• The administration of heparin and protamine to prevent bleeding complications 3
• The use of hemostatics, such as TachoSil, to reduce postoperative bleeding complications 3

Surgical Techniques

Different surgical techniques may be employed during carotid endarterectomy, including:

• Patch angioplasty without its disadvantages, as described in 2
• Simple closure of a longitudinal arteriotomy for endarterectomy, as described in 2
• The use of a medical sponge consisting of collagen with added human coagulation factors, such as TachoSil, to prevent minor bleeding 3