Carotid Endarterectomy for Cerebrovascular Events

A TIA is a sudden loss of localised brain (cerebral) function with symptoms lasting less than 24 hours with a full recovery.

A stroke is a sudden loss of localised brain (cerebral) function with symptoms lasting more than 24 hours with subsequent resolution, symptoms that continue to persist long after the initial event or if an area of abnormality from the stroke is identified on a brain scan.

Patients may present with clearly obvious abnormalities such as an inability to speak properly, facial drooping or loss of power and sensation in their arms or legs. Some patients may describe solitary or recurrent episodes of visual loss “like a set of curtains coming downwards” called Amaurosis Fugax .

Stroke is the third most common cause of death responsible for 12% of UK deaths. 125,000 people suffer their first stroke each year while 36,000 suffer a TIA each year. Half of strokes affect patients greater than 75 years of age accounting for 10% of in-patient hospital bed occupation and 5% of health care expenditure.

A stroke occurs when an area of the brain is starved of oxygen. The brain is unable to store oxygen like other parts of the body and is totally reliant on a continuous blood supply to provide it with nutrients and remove waste. Brain cells can survive 3 to 4 minutes without oxygen before they begin to die.

80% of strokes are due to a sudden reduction in blood flow, called ischaemia, often due to narrowing in a blood vessel supplying the brain or passage of a clot from elsewhere in the body that blocks one of the arteries supplying the brain. 20% of strokes are due to bleeding (haemorrhage) which can occur spontaneously, due to a trauma or as a sudden consequence of an underlying abnormality in the brain such as an aneurysm.

Your clinician will discuss your scan results with you and recommend the most appropriate treatment which may require a referral to a stroke specialist. During your initial presentation, it is important to perform an urgent CT scan of your brain to identify if a bleed has occurred. If a bleed in the brain has been ruled out, your stroke specialist will determine if you are suitable for arterial lysis treatment which involves an injection of clot dissolving medicine through a cannula in one of your veins or whether you require a procedure in the radiology department to try and remove the clot with keyhole techniques inserted via your femoral artery located in your groin area.

Most patients are subsequently commenced on best medical therapy which includes antiplatelet treatment (aspirin or clopidogrel) to thin the blood and lipid lowering medications (statins) to limit plaque progression. High dose aspirin 300mg antiplatelet treatment once a day is often prescribed for the first 2 weeks prior to switching over to clopidogrel 75mg once a day. These tablets will also have a protective effect for other cardiovascular systems in your body and will usually be required for the rest of your life. Your risk factor profile should also be optimised particularly blood pressure control and smoking cessation.

As previously described, your stroke specialist may recommend clot dissolving treatment called lysis injected into one of your veins or an intervention in the radiology department to actually remove the clot in the brain directly called clot retrieval (thrombectomy). In the presence of a significant narrowing in the carotid artery, a carotid endarterectomy may be warranted. Occasionally, a carotid stent may be suggested in patients with a history of previous carotid surgery or a previous history of other head and neck treatment such as radiotherapy.

If you have had a proven TIA or stroke and your carotid duplex ultrasound scan reports an arterial narrowing greater than 50%, your clinician will refer you to a vascular surgeon to evaluate whether this area of narrowing is amenable to surgery and whether you would benefit from an operation to clean the artery out called a “carotid endarterectomy” . Current guidelines suggest that if you are medically fit for surgery, this should be performed within two weeks of your initial symptoms.

Current NICE National Guidelines for Stroke and Transient Ischaemic Attack (Section 1.2.4 - Last reviewed 26 March 2025) state that carotid endarterectomy should be performed within 2 weeks of TIA or stroke symptoms developing. As described previously, there is not often time for an “anaesthetic pre–operative assessment” due to the urgency of surgery to prevent further TIA or stroke symptoms.

Most patients are usually admitted to hospital the day before their operation where blood tests, an ECG and chest X-ray may be performed if not already completed by the initial referring clinician. Some patients may already have been admitted to hospital through the stroke service after their initial TIA or stroke. An anaesthetist will consult with you to optimise your medications which you may be taking for your diabetes, heart and lung disease. Your vascular surgeon will visit you before the operation and ask you to sign a consent form once he has explained the procedure to you.

Most vascular operating lists require a certain degree of flexibility due to the emergent nature of clinical cases. Therefore, you may move position on the operating list from your originally planned time. Your nursing and medical team will advise accordingly. This is why all patients are fasted from midnight with no further solid food after this time. Sips of water are allowed until 6am on the day of your surgery.

You surgery may be performed under general or local anaesthetic.

If you are having a general anaesthetic, you will be put to sleep by an anaesthetist shortly before the operation starts.

Patients having local anaesthetic will remain awake and be given a series of injections to numb the skin of the neck where the incision will be placed. Patients having local anaesthetic should be aware that they may be asked to perform a series of simple tasks at certain points of the operation. These tasks include reading out words from a card, squeezing a toy or just conversing with a member of theatre staff. This is important and allows medical staff to assess how good the circulation to your brain is at any stage of the procedure. Furthermore, patients will need to stay very still during the operation in what may be a potentially uncomfortable position

After you are positioned appropriately on the operating table, the neck skin area where the carotid stenosis is present is shaved (if required),cleaned with aseptic fluid and surgical drapes are then applied to maintain a sterile operative field for the operation. An oblique incision is performed in the neck to expose the carotid artery and the arteries that it eventually divides into where the carotid stenosis is present. Blood thinning medication called heparin is then administered via one of your veins by the anaesthetist. Clamps are applied above and below the area of narrowing that has caused your symptoms. The artery is then opened and subsequently cleaned out to remove the diseased area that caused your TIA or stroke event. Once your surgeon is content the roughened and narrowed diseased segment has been addressed an “artificial” patch is then sutured in place to repair the artery, maintain good flow and minimise risk of future narrowing.

Throughout the procedure, blood supply to the brain is maintained by the carotid artery on the other side, the two vertebral arteries at the back of the neck combined with the use of a plastic tube called a “shunt” on the operative side that is used to detour blood to the brain around the artery that is being repaired. Once the patch is sutured in place, the clamps are subsequently removed from the artery to make sure there are no leaks from the patch. When your vascular surgeon is satisfied that normal blood flow in the artery has been restored, the wound is then closed with layers of sutures. The skin sutures are designed to dissolve by themselves and do not require removal. Sometimes your vascular surgeon will use skin clips instead to close the wound which then require removal between 5 and 10 days following your surgery. Finally, a drainage tube will be placed inside the wound and emerge through the skin slightly lower than your incision. It will be attached to a bottle and the amount of fluid draining subsequently will be monitored. The operation is now complete and you will be taken to the recovery area. The operation takes between 1 to 2 hours.

You will be observed closely in the recovery area for anything up to 4 to 8 hours after your operation. The medical staff will assess your clinical status by asking you to open your eyes, stick out your tongue and move both your upper and lower limbs. The nursing staff will continue to check these clinical parameters as well as your pain levels, drain output and haemodynamic observations particularly your blood pressure. If there are no problems, patients are then transferred back to the ward where they are offered something to eat and drink and encouraged to mobilise the following day.

The drainage tube is usually removed the morning after your surgery if only a small amount of blood stained fluid has collected. Most patients will have their normal diet recommenced the evening of their surgery with prescription of their normal medications particularly clopidogrel and statin therapy indefinitely. You may require an evaluation by both the physiotherapy and occupational therapy teams prior to your discharge to ensure you are safe for discharge. Patients are discharged 1 to 2 days following their surgery. On discharge, most patients do not require suture removal. Once the wound is healing nicely the dressing does not need to be replaced. Occasionally, you may be advised to contact your practice nurse for blood pressure checks as optimal control is exceptionally important following your surgery.

Normal activities and low grade exercises like walking are encouraged once you get home. It is advised to avoid strenuous activity for 2 weeks after the operation or until you feel you are able. After a single cerebrovascular event, you should not drive for 1 month. However, if you presented with multiple cerebrovascular events over a short period of time, it is advised that you should not drive for 3 months. You should also notify the Driver and Vehicle Licencing Agency and consult with your motor insurance company to ensure you are fully compliant with current guidelines.

The majority of patients having the operation have retired but those still in employment should have at least 2 weeks off work.

Your vascular surgeon will organise a follow–up appointment for you approximately 6 to 12 weeks following your surgery to assess your recovery. Most patients are discharged from the vascular surgery service at this stage. Your stoke physician may also arrange to review you as well following your surgery.

You may feel tired for a few months after your TIA, stroke and subsequent operation. You should gradually improve over time. Most patients comment that they return to normal approximately 3 to 6 months after their procedure. However, your recovery is very dependent on how your initial TIA or stroke affected you.

You should be able to bathe and shower lightly whilst your wounds are healing. It is not advised to fully immerse non-healed wounds in a bath until they are fully healed.

Following your surgery and prior to your discharge, you will receive support and advice from many members of the vascular team including physiotherapists and occupational therapists regarding activities appropriate for you during your recovery. Additional home support on discharge can be discussed with the vascular surgery social worker.