V01 Carotid Endarterectomy What is a stroke (CVA) or minor stroke (TIA)? A stroke is a loss of brain function resulting from an interruption of the blood supply to the brain. The main cause is a condition called atherosclerosis, where the walls of blood vessels become diseased, causing narrowing or hardening of the arteries. A minor stroke or TIA (transient ischaemic attack) causes only temporary loss of brain function. However, a TIA can be followed by a major stroke. Operating on your carotid artery (carotid endarterectomy) will reduce the risk of you having a stroke in the future. Your surgeon has recommended a carotid endarterectomy. However, it is your decision to go ahead with the operation or not. This document will give you information about the benefits and risks to help you make an informed decision. If you have any questions that this document does not answer, you should ask your surgeon or any member of the healthcare team. How does a stroke happen? The neck artery supplying the brain (internal carotid artery) becomes narrowed (see figure 1). The left artery supports the function of the right side of the body (including the arm and the leg) and vice versa. If you have a narrowing in your neck artery, you have a greater chance of developing a stroke. People who have had a minor stroke are more likely to have a major stroke in the future. Atherosclerosis has developed due to one or more of the following risk factors - smoking, high blood pressure, a family history of atherosclerosis, age, diabetes and high cholesterol levels. These factors also cause heart disease and problems with arteries in the legs. If you have had a stroke or a TIA within the last six to twelve months and your internal carotid artery has narrowed by more than 70% of its normal size, there is evidence to show that you would benefit from an operation to correct the problem. However, your surgeon may recommend an operation even if you have not had any symptoms. Internal carotid artery which supplies blood to the brain Figure 1 Diagram showing the carotid artery External carotid artery Common carotid artery What are the benefits of surgery? Surgery should prevent you from having further strokes. Are there any alternatives to surgery? You may already be on medical treatment such as aspirin or clopidogrel (Plavix), which helps to thin the blood. These drugs are useful in preventing further strokes but are less effective than an operation. For some people it may be possible to have a procedure to widen or unblock an artery using a small inflatable balloon. Usually a stent (metal mesh tube) is used to hold the artery open. However, there is also a risk of serious complications. Copyright 2009 V01 Page 1 of 5
What will happen if I decide not to have the operation? Your doctor will make sure that you are on blood-thinning medication and that the risk factors for this disease, such as high blood pressure, diabetes and high cholesterol levels, are treated. You will also be advised to stop smoking, as this will help prevent further strokes. However, the risk of having a stroke is higher without surgery. What does the operation involve? Before the operation, you may have a Doppler ultrasound (or Duplex scan) of your neck. The healthcare team will carry out a number of checks to make sure you have the operation you came in for and on the correct side. You can help by confirming to your surgeon and the healthcare team your name and the operation you are having. A carotid endarterectomy is performed either under a general anaesthetic or using a local anaesthetic. Your anaesthetist will discuss the options with you and recommend the best form of anaesthesia for you. You may also have injections of local anaesthetic to help with the pain after surgery. Your surgeon or anaesthetist may give you antibiotics during the operation to reduce the risk of infection. The operation usually takes between one and a half and two hours. Your surgeon will make a cut in your neck over the artery, before entering the artery. Sometimes they will temporarily clamp the artery. They may use a temporary shunt (bypass) if the blood flow in the opposite artery is poor. They will remove the lining of the artery that has become diseased (caused by atherosclerosis) (see figure 2). Your surgeon may use a patch to prevent narrowing (either a vein or an artificial patch). They will usually take the vein for the patch from one of your legs through another cut. They will then close the artery, using the patch if they need to. What should I do about my medication? You should make sure your surgeon knows the medication you are on and follow their advice. You may need to stop taking warfarin, clopidogrel or aspirin before your operation. If you are a diabetic, it is important that your diabetes is controlled around the time of your operation. Follow your surgeon s advice about when to take your medication. If you are on beta-blockers to control your blood pressure, you should continue to take your medication as normal. Copyright 2009 V01 Page 2 of 5
What can I do to help make the operation a success? Lifestyle changes If you smoke, you must try to stop smoking now. Smoking is one of the main reasons why this problem happens. Stopping smoking now can help reduce the risk of you suffering a heart attack, having further narrowing of the arteries and developing certain cancers. Stopping smoking several weeks or more before an operation may reduce your chances of getting complications and will improve your long-term health. For help and advice on stopping smoking, go to www.smokefree.nhs.uk. You have a higher chance of developing complications if you are overweight. For advice on maintaining a healthy weight, go to www.eatwell.gov.uk. Exercise Regular exercise can reduce the risk of heart disease and other medical conditions, improve how your lungs work, boost your immune system, help you to control your weight and improve your mood. Exercise should help to prepare you for the operation, help with your recovery and improve your long-term health. For information on how exercise can help you, go to www.eidoactive.co.uk. Before you start exercising, you should ask a member of the healthcare team or your GP for advice. What complications can happen? The healthcare team will try to make your operation as safe as possible. However, complications can happen. Some of these can be serious and can even cause death (risk: 2 in 250). You should ask your doctor if there is anything you do not understand. Any numbers which relate to risk are from studies of people who have had this operation. Your doctor may be able to tell you if the risk of a complication is higher or lower for you. The complications fall into three categories. 1 Complications of anaesthesia 2 General complications of any operation 3 Specific complications of this operation 1 Complications of anaesthesia Your anaesthetist will be able to discuss with you the possible complications of having an anaesthetic. 2 General complications of any operation Pain, which happens with every operation. The healthcare team will try to reduce your pain. They will give you medication to control the pain and it is important that you take it as you are told so you can move about and cough freely. Bleeding during or after surgery. This rarely needs a blood transfusion or another operation but it is common to get bruising around the cut. Infection of the surgical site (wound). To reduce the risk of infection it is important to keep warm around the time of your operation. Let a member of the healthcare team know if you feel cold. In the week before your operation, you should not shave the area where a cut is likely to be made. Try to have a bath or shower either the day before or on the day of your operation. After your operation, you should let your surgeon know if you get a temperature, notice pus in your wound, or if your wound becomes red, sore or painful. An infection usually settles with antibiotics but you may occasionally need another operation. Unsightly scarring of the skin, although the wound usually heals into a fine line. Blood clots in the legs (deep-vein thrombosis), which can occasionally move through the bloodstream to the lungs (pulmonary embolus), making it difficult for you to breathe. The healthcare team will assess your risk. Nurses will encourage you to get out of bed soon after surgery and may give you injections, medication or special stockings to wear. Copyright 2009 V01 Page 3 of 5
3 Specific complications of this operation Developing a stroke (risk: 1 in 16). A stroke can happen around the time of surgery if part of the abnormal lining dislodges and travels up to the brain. The risk of stroke is higher without an operation. Injury to the nerves supplying the muscles of the tongue (risk: 1 in 33). This is usually temporary but can occasionally be permanent. This may affect speech and eating. Injury to the nerves supplying the vocal cords (risk: 1 in 40). This is usually temporary but can be permanent. This may lead to a hoarse voice. Injury to other nerves that supply the skin or muscles around the cut, which leads to numbness, muscle weakness or continued pain. This is uncommon and usually temporary but occasionally it can be permanent. For some men, this can make shaving uncomfortable. How soon will I recover? In hospital After the operation you will be transferred to the recovery area and then either to the ward, intensive care unit or high-dependency unit for up to 24 hours. You will be able to drink once you have recovered from the anaesthetic. You should be able to go home after one or two days. However, your doctor may recommend that you stay a little longer. If you are worried about anything, in hospital or at home, contact a member of the healthcare team. They should be able to reassure you or identify and treat any complications. Returning to normal activities Your surgeon will tell you when you can return to work depending on the extent of surgery and your type of work. Regular exercise should help you to return to normal activities as soon as possible. Before you start exercising, you should ask a member of the healthcare team or your GP for advice. Do not drive until you are confident about controlling your vehicle and always check with your doctor and insurance company first. The future Most people make a full recovery and can return to normal activities. Your surgeon will advise you to have treatment with blood-thinning medication such as aspirin or clopidogrel to reduce the risk of the artery becoming narrowed again. Summary Narrowing of the carotid artery due to atherosclerosis is a common condition, which increases the risk of having a stroke. If you have had a stroke or minor stroke within the last twelve months and your internal carotid artery has narrowed by more than 70% of its normal size, you should benefit from an operation to correct the problem. If left untreated, the risk of having a stroke is higher. Surgery is usually safe and effective. However, complications can happen. You need to know about them to help you make an informed decision about surgery. Knowing about them will also help to detect and treat any problems early. Copyright 2009 V01 Page 4 of 5
Further information NHS smoking helpline on 0800 022 4 332 and at www.smokefree.nhs.uk www.eatwell.gov.uk for advice on maintaining a healthy weight www.eidoactive.co.uk for information on how exercise can help you www.aboutmyhealth.org for support and information you can trust Vascular Society of Great Britain and Ireland at www.vascularsociety.org.uk NHS Direct on 0845 46 47 (0845 606 46 47 textphone) Acknowledgements Author: Mr Bruce Braithwaite MChir FRCS Illustrations: Hannah Ravenscroft RM and LifeART image copyright 2009 Lippincott Williams & Wilkins. All rights reserved. Local information You can get information locally from: You may also find the following links useful. www.patient.co.uk www.prodigy.nhs.uk/patientinformation/ www.patientopinion.org.uk www.northamptongeneral.nhs.uk www.npsa.nhs.uk/pleaseask Tell us how useful you found this document at www.patientfeedback.org This document is intended for information purposes only and should not replace advice that your relevant health professional would give you. V01 Issued December 2009 Expires end of December 2010 www.rcsed.ac.uk www.asgbi.org.uk Copyright 2009 V01 Page 5 of 5