Carotid Endarterectomy: Everything You Need to Know

Carotid endarterectomy (CEA) is a procedure in which fatty deposits, called plaques, are surgically removed from within the carotid artery to prevent the development of stroke. The surgery may be recommended if there is evidence of reduced blood flow due to carotid stenosis (the narrowing of the carotid arteries) and/or symptoms linked to a high risk of stroke.

Computer illustration of the Human carotid artery
SEBASTIAN KAULITZKI / Science Photo Library / Getty Images

What Is Carotid Endarterectomy?

CEA involves opening one of the two carotid arteries that run along either side of the windpipe so that plaque can be removed along with underlying tissue.

This is an open surgery (involving a scalpel and incision) performed in a hospital as an inpatient procedure. It may involve general anesthesia to put you fully asleep or local anesthesia with an intravenous sedative.

CEA is typically a scheduled procedure but is sometimes used in emergencies when there is sudden acute carotid artery occlusion (blockage).

Carotid endarterectomy was first performed in 1953. Today, it is a relatively common procedure, with more than 100,000 carotid endarterectomies performed in the United States each year.

Contraindications

CEA is an alternative to carotid angioplasty and stenting (CAS), a minimally invasive procedure in which a stent is placed in the carotid artery to increase blood flow.

CAS was introduced in the 1980s and since then, there has been an ongoing reassessment of the appropriateness of CEA by the American College of Cardiology (ACC), the American Heart Association (AHA), American Stroke Association (ASA), among others.

Given that CAS is minimally invasive, equally effective, and associated with fewer serious complications, guidelines today have placed greater limitations on when CEA should and should not be used.

Among the absolute contraindications for CEA:

  • Prior history of severe stroke: Persons who have experienced a major devastating stroke with minimal recovery or a significantly altered level of consciousness should not undergo CEA. This is especially true if the blocked artery services the side of the brain that experienced the prior stroke.
  • Unfit for surgery: People who are very ill and otherwise unfit for surgery should not undergo CEA; CAS should be pursued as a treatment option instead.

Among the relative contraindications for CEA:

  • Risk of harm: CEA should not be performed if someone has a medical condition that may substantially increase the risk of complications or death. This includes people on dialysis or those who have had prior radiation therapy to the neck.
  • Complete carotid artery occlusion: CEA may be avoided if the carotid artery is completely blocked as there is no evidence that unblocking it will reduce the risk of stroke. As long as the other carotid artery is not significantly blocked, the complete occlusion may pose a lesser risk of harm since plaques are less likely to break off and travel to the brain.

In both of these cases, the benefits and risks of CEA must be done on a case-by-case basis.

Older age, on its own, is not a contraindication for carotid endarterectomy.

Potential Risks

As with all surgeries, CEA poses certain risks. Chief among them is the risk of stroke, heart attack, and a condition known as hyperperfusion syndrome.

  • Stroke: CEA can, on rare occasions, cause the dislodgement of a fragment of plaque. This can then travel to the brain and cause a severe blockage. The risk of this occurring is relatively low, hovering at around 6% for people with overt symptoms of arterial obstruction (such as shortness of breath and dizziness with exertion) and 3% for those without.
  • Heart attack: Myocardial infarction is another possible complication of CEA, although the risk can vary significantly—anywhere from as low as 1% to as high as 26%—based on a person's risk factors for an attack.
  • Hyperperfusion syndrome: Hyperperfusion syndrome is another potentially dangerous complication of CEA. When a part of the brain has been deprived of blood flow for a long time, it may lose its ability to properly regulate the flow of blood through the brain. After undergoing CEA, the sudden rush of blood can place extreme pressure on the brain, manifesting with neurological symptoms such as severe headache, confusion, dizziness, nausea, vomiting, fainting, blurred vision, seizures, and coma. The symptoms of hyperperfusion syndrome often mimic those of stroke.

Risks of CEA vs. CAS

Although studies have long shown that postoperative heart attack and stroke are equally likely with both procedures, the risk of death appears to be significantly higher if a person has a heart attack after undergoing CEA as compared to CAS.

In fact, according to a 2011 study published in the journal Circulation, people who undergo CEA have a 3.5-fold increased risk of death due to a heart attack compared to those who undergo CAS.

People who undergo CEA are also more likely to need revision surgery in the future.

Purpose of Carotid Endarterectomy

Carotid endarterectomy is used when a person is at a high risk of stroke due to atherosclerosis (the build-up for plaque) in the carotid artery. While the procedure can help prevent stroke, it is neither used to treat stroke nor considered a "cure." The carotid artery can become blocked again after the surgery if the underlying cause, such as high blood pressure, is not properly controlled.

CEA can be used if a person has symptoms of carotid stenosis (such as shortness of breath, fainting with activity, chest pains, or palpitations) or has had a transient ischemic attack (TIA or "mini-stroke") within the past six months.

CEA is also sometimes used in people who are asymptomatic if they have significant blockage of the carotid artery on imaging studies.

The indications for CEA have changed in recent years due to the increased use of CAS. Even among health authorities, there remains considerable controversy as to when the benefits of CEA outweigh the risks.

According to guidelines issued by the AHA and ASA, carotid endarterectomy may be indicated in the following groups:

  • Symptomatic patients with high-grade carotid stenosis (over 70% reduction in the internal artery size)
  • Symptomatic patients with moderate-grade carotid stenosis (between 50% and 69% reduction) if they are at low risk (under 6%) of surgical and anesthesia complications
  • Patients who have had one or more TIAs within six months with moderate-grade stenosis

In people who are asymptomatic, CEA may be considered if the person has a low risk of surgical complications (less than 6%) and over 60% reduction in the size of the internal carotid artery.

For all other individuals, the ACC, AHA, and ASA recommend CSA as the appropriate alternative, particularly if the neck anatomy is not favorable to surgery.

Preoperative Evaluation

In order to ascertain if CEA is appropriate, a doctor will first need to measure the degree of carotid stenosis. People with moderate-grade stenosis will also need to undergo a risk assessment to determine whether they are reasonable candidates for surgery.

The degree of carotid stenosis can be evaluated in one of two ways:

  • Non-invasive imaging studies: Carotid stenosis can be indirectly measured using imaging techniques such as a carotid ultrasound, computed tomography (CT) angiography, or magnetic resonance (MR) angiography.
  • Catheter angiography: Also known as carotid angiography, this minimally invasive procedure involves the insertion of a tube into the artery through an incision in the skin. A dye is then injected to view the flow of blood from the carotid artery to the brain on a live X-ray monitor. Catheter angiography is considered the gold standard in vascular imaging.

To assess a person's individual risk of complications, doctors will commonly use the Revised Cardiac Risk Index (also called the modified Goldman Index) utilized by the ACC and AHA. It scores one point each for:

The points are tallied and the final score (which can range from 0 to 6) is used to determine if the benefits of the surgery outweigh the risks.

A Revised Cardiac Risk Index score of over 2 is considered to be indicative of high risk (6% or more), while anything under 2 is considered low risk (under 6%).

How to Prepare

If CEA is recommended, you will meet with a vascular surgeon to review the results of the preoperative evaluations and discuss the specifics of your procedure. You will also be given instructions on what to do to prepare for surgery.

Location

Carotid endarterectomies are performed in the operating room of a hospital. The operating room will be outfitted with an anesthesia machine, a mechanical ventilator, an electrocardiogram (ECG) machine to monitor heart rate, a pulse oximeter to monitor blood oxygen, and a "crash cart" to be used in the event of a cardiovascular emergency.

CEA is an inpatient procedure typically involving a one- to two-day hospital stay. Arrange for a friend or family member to drive you home when you are released. However well you may feel after your hospital stay, carotid endarterectomy is still surgery and requires a period of recovery before you are able to operate a vehicle safely.

Food and Drink

You will need to stop eating at midnight the night before your surgery. On the morning of, you can have a few sips of plain water to take any medications your doctor approves. Within four hours of the surgery, do not take anything by mouth, including gum, breath mints, or ice chips.

Medications

You will need to stop taking certain medications that promote bleeding anywhere from one to a week before your surgery. Other drugs that affect blood pressure, heart rate, or heart rhythm may need to be temporarily stopped as well.

To avoid complications, advise your doctor about any medications you take, including prescription, over-the-counter, herbal, nutritional, or recreational drugs.

Drug When to Stop Reason
ACE inhibitors Morning of surgery May affect blood pressure
Anticoagulants 3-5 days before surgery May promote bleeding, slow healing
Beta blockers Morning of surgery May affect heart rate and rhythm
Digoxin Morning of surgery May affect heart rate and rhythm
Diuretics Morning surgery May affect blood pressure
Diabetes medications, including insulin 2 days before surgery May cause an abnormal drop in blood pressure
Nonsteroidal anti-inflammatory drugs 5-7 days before surgery May promote bleeding, slow healing

What to Bring

Pack whatever you may need during this time, including toiletries, chronic medications, and so on. You can bring pajamas, a robe, socks, and a pair of slippers to wear while you are in hospital. For your return home, pack a comfortable outfit with a shirt that buttons or zips close, rather than a pullover, as you will have stitches and bandages on your neck.

Leave any valuables at home. You will need to remove contacts, hairpieces, hearing aids, dentures, and mouth and tongue piercings prior to the surgery. If you don't need these during your hospital stay, leave them at home as well.

You will need to bring your driver's license or some other form of government ID as well as your insurance card. You may also need to bring an approved form of payment if copay or coinsurance costs are to be paid upfront.

What to Expect on the Day of Your Surgery

On the morning of your surgery, you will be asked to wash with a surgical skin cleanser to help remove harmful bacteria. After showering, do not apply makeup, lotion, ointments, or fragrances.

Most carotid endarterectomies are performed in the morning. Try to arrive 15 to 30 minutes before your scheduled admission time to fill out forms and compensate for any delays in your check-in.

Once you have registered and have signed the necessary consent forms, you are shown to your hospital room or a waiting area by a nurse, who will begin to prep you for surgery.

Before the Surgery

You will be asked to change out of your clothes and into a hospital gown. The nurse will perform standard preoperative procedures, including:

  • Vital signs: The nurse will take your blood pressure, temperature, and heart rate as well as record your weight and height to help calculate medication doses.
  • Blood tests: This may include a complete blood count (CBC), comprehensive metabolic panel (CMP), and arterial blood gases (ABG) to check your blood chemistry.
  • ECG: Adhesive electrodes will be placed on your chest to connect to the ECG machine to monitor your heart rate.
  • Pulse oximetry: A pulse oximeter is clamped to your finger to monitor your blood oxygen saturation levels throughout the surgery.
  • Intravenous catheter: An intravenous (IV) catheter is inserted into a vein in your arm to deliver anesthesia, medications, and fluids.
  • Electroencephalogram: A plastic cap with electrodes may be placed on your head to connect to an electroencephalogram (EEG) machine. This can monitor for abnormal brain functioning in high-risk individuals.

If your neck is hairy, your nurse will need to shave you. It is better not to shave the area yourself as stubble may grow between the time you shave and the time you are prepped for surgery.

During the Surgery

Once you are prepped and wheeled into the operating room, you will be given either local anesthesia or general anesthesia. Neither has been shown to be better than the other for surgeries like these. An anesthesiologist will be there to administer whichever form is chosen.

  • If local anesthesia is used, injections will be given to numb the surgical site. It is typically administered with monitored anesthesia care (MAC), a form of IV sedation that induces "twilight sleep."
  • If general anesthesia is used, it is delivered directly through the IV line to put you completely to sleep.

Once you are anesthetized and covered in sterile sheets, the surgeon will make a 2- to 4-inch incision on the neck to access the carotid artery. The artery itself is then clamped at different places to keep it from bleeding during the procedure.

Depending on the degree of obstruction, the surgeon may decide to place a temporary shunt to maintain adequate blood flow to the brain. (A shunt is simply a small plastic tube that diverts blood around the section of artery being operated on.)

To remove the accumulated plaque, the surgeon first makes a longitudinal (lengthwise) cut on the artery and uses retractors to hold it the incision open. The plaque is then stripped away in its entirety with the underlying layer of tissue, called the tunica intima.

Afterward, the inside of the vessel is washed with a saline solution and checked to ensure that all debris has been cleared.

Once the vessel is stitched, the shunt and clamps are removed. If there is no bleeding, the surgeon closes the skin incision with sutures and bandages the incision site.

After the Surgery

After the surgery, you are wheeled into the post-anesthesia care unit (PACU) and monitored until you are fully awake. For procedures involving MAC, this may take 10 to 15 minutes. For general anesthesia, it may take up to 45 minutes.

Once your vital signs have normalized and there are no signs of complications, you are wheeled to your hospital room.

The duration of the hospital stay is largely dependent on your age, general health, and cardiovascular risk factors. Hospitalization for this procedure is required specifically to monitor for any postoperative complications that may occur, including heart attack or stroke. If such an event occurs, it is better that it does in hospital where it can be aggressively treated.

Pain relievers are provided during your stay if needed. You are encouraged to walk as soon as you can to improve blood circulation and reduce the risk of blood clots.

Once the surgeon is reasonably assured that there are no immediate postoperative complications, you are released to recover at home.

Recovery

During this time, you will be advised to rest and limit physical activity for the next week or two. Ideally, a friend or family member will stay with you for at least the first few days to help you out and monitor for any signs of trouble. Do not drive until the doctor gives you the OK.

For the first five to seven days, you will need to change the dressing on your wound daily, cleaning it with the appropriate antiseptic before covering it with a fresh dressing. Do not use rubbing alcohol, hydrogen peroxide, or iodine, which can harm the tissue and slow healing.

Infection is uncommon but can occur, usually if care instructions are not adhered to.

When to Call Your Doctor or Go to the ER

Call your surgeon immediately if you experience any possible signs of a serious postoperative infection, which requires immediate treatment. These include:

  • Excessive pain
  • Redness
  • Swelling,
  • Drainage from the incision
  • High fever or chills

If you develop a severe headache in the days following the surgery, seek immediate emergency care. Do not delay. This may a sign of stroke or hyperperfusion syndrome, the latter of which can lead to seizures or coma if left untreated.

Most people who undergo CEA can return to normal activities within two to three weeks. The neck incision may take up to three months to fully heal and will typically fade to a fine line if properly cared for.

Follow-Up Care

You will usually meet with your surgeon within a week or two of your surgery. During the visit, the doctor will remove the stitches and check to see if the wound is healing properly. An in-office carotid ultrasound may be performed to check the status of the carotid artery. A CT scan may also be ordered.

In addition to your surgeon, follow-up appointments will be scheduled with your cardiologist or general physician to address any underlying factors that contributed to your condition (such as hypertension, high cholesterol, uncontrolled diabetes, or obesity). Unless these conditions are properly addressed and treated, there is every chance that arterial blockage will recur.

In addition to medications to control your underlying condition, every effort should be made to exercise routinely, eat a low-fat diet, and lose weight if needed.

A Word From Verywell

Up until the 1990s, carotid endarterectomy was considered the standard of care for people with severe carotid stenosis. Although CEA is still extremely beneficial if used appropriately, carotid stenting has become safer and more effective in recent years and may be the more appropriate option in certain cases.

If CEA has been recommended, ask the doctor why it is the better option compared to CAS. If in doubt about the recommendation—or you simply need confirmation that it is the best choice for you—do not hesitate to seek a second option from a qualified cardiologist or vascular surgeon.

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