Carotid stenting and carotid endarterectomy

The aim of carotid stenting and endarterectomy is to prevent strokes

Many strokes and mini-strokes are due to blockages of the carotid arteries in the neck which supply the brain with blood. The carotid artery in the neck is a common place to develop atherosclerosis. This condition is explained in detail in the atherosclerosis section of the website (see Conditions Treated, Prevented and Cured).

Carotid arteries affected by atherosclerosis develop a rough irregular surface which can cause blood clots to form which break off and lodge in the brain causing a stroke.

Blockages in the carotid artery can be corrected in two ways. One technique is to operate on the artery to remove the blockage and repair it to leave the artery smooth and wide open. This operation is called carotid endarterectomy. It is highly effective at reducing the risk of stroke.

An alternative method is carotid artery stenting. This involves passing a small balloon across the carotid narrowing and inflating the balloon to open the artery to improve blood flow. The artery is then held open by a stent which is a fine metal frame to prevent the artery narrowing down again after the procedure.

Carotid artery disease is explained in more detail in the Strokes and TIAs section of the website (see Conditions Treated, Prevented and Cured).

Pre-carotid stenting

Post-carotid stenting

Carotid artery stenting

Carotid artery stenting is a relatively new way of correcting blockages of the carotid arteries with the same goal as carotid endarterectomy; to reduce risk of stroke. The procedure is done under local anaesthetic. A fine wire and catheter are inserted into the femoral artery in the groin and passed up into the neck under X-ray guidance. A balloon is inserted along the wire across the blocked artery, and the balloon inflated to open up the area of narrowing. A stent (fine metal mesh tube) is then inserted to hold the artery open after the balloon has been withdrawn.

The problem with passing wires, catheters and balloons past a diseased artery is that it may cause debris to break off and lodge in the brain causing a stroke. For this reason, most carotid artery stenting devices are equipped with a so-called cerebral protection device which is a filter to catch any debris before it can pass to the brain and do damage.

Carotid artery stenting has the advantages of avoiding any incisions, and there is no risk of damage to nerves in the neck. There is uncertainty over whether the risk of stroke during carotid stenting is greater than carotid surgery. Numerous trials have compared the two techniques but there is still considerable controversy over which one is better.

Carotid endarterectomy (courtesy of Vascutek) Click picture for a better view

Carotid Endarterectomy

Carotid endarterectomy involves exposing the carotid arteries, opening the vessel and carefully removing the diseased plaque leaving a smooth internal lining. The artery is usually closed with a patch to avoid narrowing. A shunt may be used during the operation to preserve blood flow to the brain while the artery is reconstructed. The operation can be performed under local or general anaesthetic. We generally prefer the local anaesthetic technique so the patient remains conscious throughout, which is the most sensitive form of cerebral monitoring. Transcranial doppler is also used to monitor brain blood flow during the operation.

The operation takes about 60-90 minutes and most patients are discharged home 24 to 48 hours post-op.

Side effects of carotid surgery

Carotid endarterectomy has a risk of death and stroke of around 2-6%. This is much less than the risk of stroke or death from leaving the artery untreated. The other main complication is damage to important nerves in the area. The most important ones are the hypoglossal nerve which controls the tongue, mouth, and branches of the vagus nerve which supply the voice box. Some patients notice their voice is a little hoarse afterwards, or that their tongue feels clumsy. Fortunately these problems are fairly uncommon, and usually temporary. It is also quite usual for the skin around the scar to feel numb in places. This sometimes feels a little odd when shaving but is of no great consequence and returns to normal eventually.

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