Carotid endarterectomy (CEA) is a surgical procedure used to treat plaque buildup (atherosclerosis) in the carotid arteries, which run up the neck and supply oxygen-rich blood to the brain. During surgery, the plaque is stripped away from the inner lining of a carotid artery, increasing blood flow to the brain. As a result of the procedure, there is a lowered risk of stroke.

Patient selection for carotid endarterectomy has historically presented a challenge for physicians. On the one hand, the procedure has been shown to reduce risk of stroke among certain patients. However, this benefit has to be balanced against the risk of complications, especially the possibility of a stroke occurring as a result of the surgery. Also, there has been significant disagreement about the benefit of carotid endarterectomy in patients who are not experiencing symptoms related to their condition (e.g., they are asymptomatic).

A number of large clinical trials have been conducted over the past 15 years as research groups attempt to identify the best patient groups for this procedure. In 2005, the American Academy of Neurology (ANN) looked at results of these trials and issued the following guidelines:

• Carotid endarterectomy shows significant benefit for patients with symptomatic disease and a 70 percent to 99 percent blockage of their carotid arteries.
  
  
• A lesser benefit was found for symptomatic patients with 50 percent to 69 percent blockage, but there was still a benefit.
  
  
• Data is mixed for patients with asymptomatic disease, but in general, there is a benefit for patients with 60 percent to 99 percent blockage, providing there is a low rate of complications during the surgery itself.
  
  
• Carotid endarterectomy is not recommended for patients with less than 50 percent blockage.

It is important to note, however, that these are only general guidelines. Every individual case is different, and many other factors may affect the decision to recommend carotid endarterectomy. Such factors include age, gender, overall health and concomitant, or additional, health concerns, such as the presence of coronary artery disease. Finally, the success of this procedure is closely associated with the experience of the surgeon performing the operation.

Patients scheduled for surgery should prepare for a two-day stay in the hospital. They can expect an aching feeling in their neck after surgery, which should be gone within two weeks.

Carotid endarterectomy (CEA) is a surgery used to treat plaque buildup (atherosclerosis) in the carotid arteries that supply oxygen-rich blood to the brain. This plaque buildup is called carotid artery disease.

Untreated, clogged carotid arteries are a major risk factor for stroke. Strokes may be caused when the arteries become completely occluded (blocked); when the plaque ruptures, causing rapid formation of a local blood clot; or when the plaque ruptures and sends pieces of debris showering down the arterial tree to become stuck in narrow arteries. This kind of stroke is known as an ischemic stroke and accounts for the majority of strokes.

CEA surgeries are meant to prevent this by debulking the carotid arteries. During a CEA, the surgeon removes the entire inner layer of the artery, stripping away the plaque that has formed along its length. As a result, the artery is widened enough to allow the free flow of blood through it.

Because of these risks, there has been a great deal of debate among physicians about the effectiveness of CEA. It was first introduced about 45 years ago and gradually gained widespread acceptance, despite the fact that no studies had been done on its ability to prevent stroke. By the 1980s, more than 100,000 CEA surgeries were performed every year. Later studies estimated that as many as one-third of those surgeries were unnecessary. Because of this concern, the number of CEA surgeries dropped dramatically (to a low of 67,000 annually in 1991), but rebounded again to 131,000 annually in 1991.

Hoping to further refine the guidelines, in 2005, the American Academy of Neurology (AAN) Therapeutics and Technology Assessment Subcommittee analyzed data from several clinical trials and issued new guidelines to help physicians identify patients for whom CEA might help. The new guidelines include:

• CEA was shown to reduce the risk of stroke for symptomatic patients with 70 percent to 99 percent blockage by 16 percent over five years.
  
  
• Symptomatic patients with 50 percent to 69 percent blockage experience a 4.6 percent risk reduction over five years.
  
  
• Patients who do not have symptoms (e.g., are asymptomatic) with 60 percent to 99 percent blockage may experience benefit, assuming that the patient is between 40 and 75 years of age, has an expected lifespan of five years, and the rates of stroke or death during surgery can be reliably documented to be less than 3 percent.
  
  
• CEA is not recommended for patients with less than 50 percent blockage whether they have symptoms or not.
  
  
• Patients benefit from low-dose pre- and postoperative aspirin (81 mg or 325 mg), versus high-dose regimens (650 mg or 1,300 mg).
  
  
• Women with 50 percent to 69 percent blockage may derive little or no benefit from CEA, compared to men.

When formulating these guidelines, researchers found that if the complication rate is less than 3 percent, CEA is easier to justify. The most serious complication associated with CEA is the risk that, during the surgery, bits of plaque will shower downstream and actually cause a stroke.

This risk seems directly related to the experience of the surgeon. Less experienced surgeons report stroke rates as high as 10 percent, particularly among patients who have symptoms of stroke. By contrast, more experienced surgeons report stroke rates around 3 percent in symptomatic patients and as low as 1 percent for patients without previous symptoms of stroke.

Other research has indicated that African American men are less likely to have a carotid endarterectomy than white men. Researchers propose that physicians might not be communicating effectively with their African American patients about CEA and how it can help prevent a stroke.

Research has shown that CEA procedure can be safely performed on elderly individuals, provided they are deemed medically fit.

Obtaining a second opinion is always important when it comes to major surgery. In particular, patients who do not understand their physician, who do not feel comfortable asking their physician questions or who feel like their physician is not listening to/understanding what they have to say are encouraged to seek a second opinion. Furthermore, patients should ask specifically about a particular surgeon’s history of reducing patients’ overall risk of stroke, as well as their risk of stroke during the procedure.

As an alternative to the CEA procedure, in 2004 the Food and Drug Administration approved a less invasive method of treating carotid artery disease. Called carotid artery stenting, the procedure involves the placement of a specialized stent within the carotid arteries to keep the arteries open. Several studies have suggested that carotid artery stenting may be as effective as surgery in some cases, although CEA remains the "gold standard" to treat advanced carotid artery disease.

In general, stenting may be appropriate if a patient has had a stroke already, has a carotid artery that is at least 80 percent blocked, and is not a good candidate for surgery.

People should prepare for a hospital stay of one to two days. Eight hours before surgery, all patients are placed on NPO (non per os; nothing by mouth) status. That means they are not permitted to eat, drink or take anything by mouth until after their surgery. Smokers will have been instructed to completely avoid smoking for at least two weeks before their surgery to prevent problems in blood flow, clotting or breathing. Certain medications may need to be reduced or stopped temporarily, so patients should discuss their medication schedules with their physician before surgery.

Immediately before the procedure, the patient will be prepped for surgery. In most cases, he or she will be given a sleep-inducing medication (general anesthesia), although local anesthesia may be used instead so the patient is numbed but awake.

The vascular surgeon makes an incision in the neck to expose the carotid artery. Occasionally, a bypass tube is inserted into the artery above and below the blockage, creating a temporary detour for blood to flow around the blockage.

Once the vessel is exposed, the surgeon scrapes away the inside layer of the artery, stripping away the plaque that has formed along its length. When the process is complete, the physician stitches the artery closed, with or without a patch of either natural or a synthetic material. Blood can then flow freely through the carotid artery.

After surgery, patients are frequently out of bed the next day and discharged after an overnight stay. During that time, the patient will probably experience an aching feeling in the neck. It may take two weeks until the patient feels completely healed.

The main benefit of the carotid endarterectomy is prevention of future stroke. It may also alleviate any stroke-like warning signs that people had been experiencing, such as unusual weakness on one side of the body or temporary vision problems.

There are a number of risks associated with the procedure, including heart attack, stroke or death.

Post-surgery risks include:

There are a number of additional questions that are also under consideration, including whether or not CEA benefits patients who are currently experiencing a stroke, what is the best timeframe after a stroke or transient ischemic attack for the surgery, and the effectiveness of CEA combined with coronary artery bypass graft (CABG) surgery to treat coronary artery disease.

Recent research suggests that performing both procedures at the same time increases the chance of a stroke occurring. While further evaluation is needed to substantiate these findings, patients may want to discuss the possibility of increased risk from this procedure with their physician.

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to carotid endarterectomy (CEA):

1. What sorts of risks are associated with a CEA?
   
   
2. What percentage of blockage is present in my carotid arteries?
   
   
3. What other factors besides the degree of carotid artery disease are factoring in your recommendation?
   
   
4. Is a CEA likely to improve my condition? Is it worth the risks involved?
   
   
5. Are there any alternatives to undergoing this procedure? Is there a safer type of procedure that can be performed instead? What about carotid artery stenting?
   
   
6. Who will be performing the surgery? How many of these procedures has he/she performed?
   
   
7. What do I need to do to prepare myself for the procedure?
   
   
8. What sort of difference can I expect days and months after the procedure?
   
   
9. What is the likelihood that I will have to repeat this surgery?
   
   
10. Should I follow a special diet after the surgery?
    
    
11. Does alcohol use worsen my condition?
    
    
12. How long after surgery should I wait to start exercising?