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Patient Information - Carotid Endarterectomy at QMC

1. What is the problem?
Every day in Great Britain, many people have a stroke ("CVA") or warning signs of a stroke ("mini stroke" or transient ischaemic attack "TIA"). Such patients are at a higher risk of having another, perhaps major, stroke. All patients with an increased risk of stroke are given medical treatment and advice to reduce this risk. This includes treatment of high blood pressure, diabetes, high fat levels, heart disease and stopping smoking. In addition, aspirin is generally given.

However, in many cases, surgical treatment is also recommended. In these cases, such as yourself, there is a narrowing of the artery in your neck that supplies blood to the brain. This trouble is due to hardening of the arteries (atherosclerosis). It is important to realise that the left side of the brain looks after the right arm and leg and the right side of the brain looks after the left arm and leg. For this reason, the patient often thinks that the "wrong" side is being operated upon when in fact it is the correct side!

At present, we also know that the presence of a narrowing (stenosis) in your carotid artery makes the chances of suffering a stroke in the future much higher than in a person without such a narrowing. We also know that performing an operation called carotid endarterectomy (to correct the narrowing) will actually reduce the chances of stroke and /or death significantly.


2. How do I know I need an operation?
Your General practitioner or perhaps opthalmologist may have referred you to a vascular specialist. If you have been asked to see Mr Braithwaite, he will probably arrange for you to be seen in the vascular "one-stop" clinic at the Queen's Medical Centre in Nottingham. At that appointment, he will ask you some questions and may arrange for you to have a duplex scan of your neck. This is a special ultrasound scan that takes about 10 to 15 minutes. One of the vascular technicians will place some special jelly on your neck and then use a painless scanner to look at the flow of blood in the arteries to your brain.

If the scan shows a narrowing of more than two thirds (70%) then Mr Braithwaite may suggest that you have an operation. If the narrowing is less than 70% then he may advise that you take aspirin and a new drug called plavix to help make your blood less sticky.

 

 

3. Why do I need an operation?
We know form several large studies that people with a carotid artery that is narrowed and who have had symptoms of a stroke benefit from an operation. 

The narrowed part of the artery is often rough and blood clots on this rough patch. If the clotted blood breaks off (platelet emboli) then it can lodge in an artery in the brain. This means that area of the brain stops working and that cause the symptoms of a stroke.

Carotid endarterectomy is an operation that removes the rough patch and so stops the blood from forming platelet emboli.

 

4. What happens when I need an operation?
Surgery involves admission to hospital for about five days and will generally be carried out on the day of admission. 

Before the operation you will be seen by Mr Braithwaite and the nursing staff in a pre-admissions clinic to discuss the operation again and to have any tests done if they have not already been carried out. 

On the day of the operation or perhaps the night before, you will be seen by the anaesthetist who will be part of the operating team. 


5. The operation.
Most of the carotid endarterctomy operations done by Mr Braithwaite are performed when people are awake. This is safer for you as we can monitor the effects of temporaily stopping blood flow in the artery on one side of your neck. If you have the operation done when you are awake then you will have a special anaesthetic that numbs your neck. In addition, you may have a sedative injection.

For some people it is better to have a general anaesthetic. If this is the case then Mr Braithwaite will discuss the reasons. Very occasionally it is necessary to give you a general anaesthetic when we start with a local one. If this happens, Mr Braithwaite will explain why.

Once you have been anaesthetised a cut is made in the skin of the neck over the carotid artery. The artery is then temporarily clamped off and the diseased lining removed. The artery is then closed. Sometimes a patch of vein or artificial artery is used to prevent narrowing.  Either metal staples or stitches will be used to close the skin and there may be a drainage tube placed which will be taken out after 24 or 48 hours.


6. After the operation.
When you wake up, you will find that your arm is connected to one or two plastic tubes to provide you with fluids and to monitor your blood pressure. You will usually be returned to a high dependency unit (HDU) so that we can keep a special eye on you for 24 hours. After this you will be returned to your own ward. You will be allowed to drink after you have woken up completely from the anaesthetic. The operation itself is not particularly painful although you may need some painkillers, which will be given to you if required. In some cases, you may be able to give yourself medication and you will be shown how to do this. On the following day after surgery you will be allowed to get out of bed and to eat normally. In many cases, you may be allowed home on the second or third post-operative day. Arrangements will be made to remove the skin staples or sutures, if they are not removed before you leave.


7. What happens when I go home?
You will be a little sore and bruised after the operation. Sometimes your mouth may have a slight droop but this will recover.

You can return to normal activities as soon as you feel able to.

You can shower and bath as normal.

Continue to take your aspirin unless you have been advised otherwise by Mr Braithwaite.

 

8. Are there any risks?
Some minor bruising around the wound is common after the operation. Sometimes a blood transfusion is necessary although this is uncommon. Bruising of the neck may take several weeks to settle down. There is likely to be a numb area on the side of the neck that may take several months to settle down. Occasionally this numbness can be permanent. Temporary weakness of the side of the mouth or tongue is possible though it is only very rarely permanent. 

There is a small (but finite) risk of developing a stroke during the operation combined with a very small risk of death. In Great Britain, this combined "operative" stroke and death risk is less than 5% (1 in 20 cases). However, surgery stops you from having a major stroke in the long run. You may wish to discuss these risks with your Surgeon in more detail before the operation.


9. What about afterwards?
You will usually receive an appointment to be seen in the outpatient clinic in about one months time. 

The operation usually gives good long-term relief. You can also help by improving your general health by taking regular exercise, stopping smoking and reducing the amount of fat in your diet. All these things will help reduce the chances of further trouble from arterial disease.