Carotid Endarterectomy

What is Carotid endarterectomy?

It is an important surgery used to prevent stroke by repairing constriction (Stenosis) in the common catroid artery. It is primarily used in individuals suffering from Cartoid Artery Disease.

The process is abbreviated as CEA.

Carotid Endarterectomy ICD 9 Code

The ICD 9 Code for Carotid Endarterectomy is 38.1.

Why is Carotid endarterectomy Performed?

It is mainly conducted to remove fat-filled plaque from the arteries located in the neck. Cartoid Artery Disease leads to the deposition of fatty plaque on the interior walls of the carotid arteries in the neck. The condition affects the vessels directed towards the head and the brain. The cells of the brain require a constant supply of oxygenated blood to survive and function. Blood is supplied to the brain by two large carotid arteries at an anterior position of the neck and two smaller vertebral arteries situated at a position posterior to the neck. Plaques are small, unusual patches that can be found inside the body. These are composed of calcium, fat, cholesterol and other materials found in the bloodstream. Over a period of time, these plaques harden and constrict the carotid arteries. When the carotid arteries get obstructed, the brain does not receive enough oxygen. This gives rise to a stroke. Carotid endarterectomy is carried out to remedy this condition. During this operation, surgeons make a cut (incision) in the neck and take out the accumulated plaques from a carotid artery. This helps restore normal flow of blood through the artery.

Carotid endarterectomy Procedure

This surgical process takes approximately a couple of hours to be performed. However, the time involved for making preparations and administering of anesthesia can increase the total duration involved for surgery. Prior to the surgery, vascular surgeon or physician may give certain instructions that patients need to follow, such as fasting. Before the operation is carried out, doctors may carry out a common test called Duplex Ultrasound to find out the extent of plaque accumulation in the arteries. This painless examination involves using sound waves to display the blood vessels and determine the speed of blood flow within them. The test can also help specify the location and extent of constriction in the carotid artery. Vascular surgeons may also use other tests, such as:

• Angiography (or arteriography)
• Computed tomographic angiogram (CTA)
• Computed tomography (CT) scan
• Magnetic resonance angiography (MRA)

The actual operation involves using anesthesia to put patients to sleep. Alternately, surgeons or anesthesiologists can choose to induce localized numbness in the neck region. This is done to keep patients awake so that they may communicate with the surgeon while the operation is being carried out. If patients stay awake, physicians can monitor more easily the reaction of the brain to reduced blood supply.

Whether the patient is conscious or unconscious, surgeons shave the skin of the neck region that is going to be the site of operation. Shaving the skin prior to an incision helps prevent outbreak of infections. This is followed by performing an incision on one side of the neck. This helps display the obstructed carotid artery. Next, the surgeon clamps the carotid artery temporarily to stop flow of blood through it. During operation, the brain gets blood supply from the carotid artery located on the other slope of the neck. Alternately, surgeons may also put in a shunt to move the blood in a roundabout way around the artery that is being fixed.

Once the carotid artery has been clamped, the surgeon directly makes an incision into the obstructed section. Next, the deposited plaque is peeled off by removing the inner lining of the affected arterial section that contains the plaque.

After the plaque has been removed, the surgeon sews the artery and takes off the clamps or the shunt. Bleeding, if any, is stopped. The neck incision is closed and the process is completed. As part of the surgical process, a patch is often used to broaden the artery. The material of the patch can be a vein of the patient, often taken from the leg, or various synthetic materials – whichever is deemed fit by the surgeon.

Carotid endarterectomy and Stroke Symptoms

In some cases, individuals with an obstruction in the carotid artery may suffer from symptoms related with a stroke, such as:

• Vision defects
• Slurred speech
• Mental confusion

Asymptomatic individuals with arterial blockage diagnosed during a physical test may display a bruit or an unusual sound related with defective flow of arterial blood. If a bruit is detected, further tests may be ordered to make greater evaluation of the condition of the carotid arteries of the affected individual.

Carotid endarterectomy Indications

It often becomes difficult for surgeons to decide who are eligible for a CEA operation. Surgery is indicated when patients are symptomatic and have more than 70% carotid artery stenosis. Surgery is also deemed appropriate in a asymptomatic or symptomatic patients with over 60% stenosis, especially if

• Ulcers are found on the plaque
• Patients show symptoms even when administered with aspirin
• The opposite carotid artery is obstructed
• CT or MRI scans of a minor stroke shows that no symptoms were produced
• The extent of Stenosis is higher, especially if progressive narrowing is demonstrated in serial studies
• The patient is comparatively young

Patients are considered fit for the process if they suffer from acute narrowing of the carotid arteries, particularly if they experience TIA (Transient Ischemic Attack) or have fairly good health otherwise. Patients, however, can be eligible but at a comparatively heightened risk of complications, if they have:

• Unstable angina (chest pains)
• Congestive heart failure
• A heart attack sometime in the past six months
• A major stroke without recovery
• Major cancer, with a life expectancy that is less than two years
• High blood pressure not properly controlled by medications or changes in lifestyle
• Symptoms of some progressive brain syndrome, such as Alzheimer’s disease

Carotid endarterectomy Contraindications

The process should not be performed if:

• Stenosis is lower than 50% in a symptomatic patient
• Stenosis is lower than 60% in an asymptomatic sufferer
• The sufferer is in poor health condition
• Studies show a recent large section of dead brain in the patient
• Death or surgical incidence of stroke is higher than 3%

Carotid endarterectomy Recovery Process

Following surgery, patients may need to spend 1 or 2 days in a special post-operative-care unit or an intensive care unit (ICU). During this time, patients are closely monitored by a physician to examine their progress. Doctors make sure that patients have normal blood pressure and brain functioning. Patients are also observed to check whether they have any bleeding from the neck region. In the early stages of recovery, they are usually administered with nutrients and fluids through a tiny, thin tube known as an intravenous (IV) catheter. Patients recuperating from surgery do not experience any major painful symptoms due to the small size of the neck incision.

At the time of discharge, physicians typically recommend patients to avoid driving and reduce physical activities for several weeks to come. They are advised to seek immediate medical assistance if they suffer from severe headaches or swelling in the neck or observe any change in brain function.

After surgery, patients may be given a medication for use at home. The drug reduces the possibility of blood clotting after operation. It may be used for a few weeks.

Patients are usually able to return to a normal, active lifestyle several weeks after the surgery.

Carotid endarterectomy Management

Around 6% patients suffer from a possibility of having a re-obstruction of the carotid artery. To avoid this condition, physicians recommend certain lifestyle changes for sufferers. These include:

• Exercising regularly
• Maintaining a proper body weight
• Avoiding foods rich in saturated fat and cholesterol
• Avoiding smoking
• Controlling high pressure and diabetes
• Follow-up visits to doctor at regular intervals

Left Carotid endarterectomy

This surgical process is performed when plaque or fat deposits are detected in the internal carotid artery. The process is conducted only the location of the obstruction has been clearly confirmed by an imaging test. The process is exactly similar to as any other type of Carotid endarterectomy. The difference is only in the way the process is implemented by a doctor.

The surgery is risky in nature and may cause death in some cases. Following the initial stages of recovery, patients may require subsequent scans to help doctors check how much successful the operation has been.

Right Carotid endarterectomy

The process is conducted to remove fat or plaque that is obstructing the right carotid artery. The surgery is performed immediately after an obstruction has been detected in the region. Right carotid endarterectomy surgery is a very important operative process that should never be delayed in any condition. It is quite similar to any other form of carotid endarterectomy as the preparation and incision point are similar. Patients should immediately report to doctors about any painful symptoms after the operation. Once the surgery is completed, patients should follow a proper diet.

Following surgery, patients generally recover in two or three days. During recovery, patients should again be scanned to determine the success of the process. If it is found to be successful, patients are discharged and gradually allowed to return to a normal, active lifestyle over time.

Bilateral Carotid endarterectomy

This surgical process involves both carotid arteries. It is highly effective in removing blockages of the cartoid arteries. However, it involves certain complications for patients who have to undergo the process. Vocal cord paralysis is one of the most dreaded complications of this process. The condition typically arises in patients of bilateral high grade stenois on whom the operation is carried out. Due to this surgeons opt for separating Carotid endarterectomy into stages and carrying each staged operation after 4 to 6 weeks.

Carotid endarterectomy Pictures

Here are some assistive Carotid endarterectomy photos. These Carotid endarterectomy images will let you get an idea about how the surgical process is carried out.

Picture 1 – Carotid Endarterectomy

Picture 2 – Carotid Endarterectomy Image

Carotid endarterectomy Video

Here is a useful video that will help you understand how this surgical process is performed in an ideal medical setting.

Carotid endarterectomy Risks

Quite a few risks are involved with this operative procedure, as is the case with most surgeries. The operation can involve acute complications. In extreme cases, stroke and death may also occur. Although CEA aims at reducing possibilities of a stroke, it actually results in one in certain cases. Stroke, however, is a rare complication and only occurs in 1-3% cases of people undergoing CEA.

Another abnormal complication is the recurrence of obstruction of the carotid artery. The condition is known as Restenosis and may arise later. The possibility of development of this condition is particularly higher in individuals who continue to smoke cigarettes. Generally, only about 2 to 3 percent patients have a possibility of developing a Restenosis that is acute enough to require another CEA surgery.

Temporary nerve injury is another rare but possible complication of this condition. It gives rise to various discomforting symptoms, such as:

• Hoarseness
• Swallowing difficulties
• Numbness in face or tongue

Short-term injuries of nerve generally resolve within a month and do not require any treatment. However, the possibility of a stroke can be much higher than any of these unusual complications if a significant carotid obstruction is not treated properly.

In some cases, patients also suffer from additional complications which include breathing difficulties and infection. Other complications include hemorrhage, hypoglossal nerve damage and Hyperperfusion Syndrome.

If you are suffering from Cartoid Artery Disease, consult your doctor to know whether CEA is the best treatment option for you.

References:

http://www.vascularweb.org/vascularhealth/Pages/carotid-endarterectomy.aspx

http://www.nhlbi.nih.gov/health/health-topics/topics/carend/

http://texheartsurgeons.com/CarotidEndarter.htm

http://www.strokecenter.org/patients/stroke-treatment/carotid-endarterectomy/

http://www.yoursurgery.com/ProcedureDetails.cfm?Proc=9