New York Health - Should I have carotid endarterectomy for stroke or transient...

Introduction

This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.

Key points in making your decision

Carotid endarterectomy is surgery to remove plaque buildup that causes narrowing (stenosis) in the carotid artery. The surgery is done to reduce your risk for transient ischemic attack (TIA) and stroke. But your doctor may recommend surgery only if you have moderate to severe narrowing and a low risk of complications from the surgery.

Consider the following when making your decision:¹

You are most likely to benefit from surgery if you have had symptoms (a prior TIA or mild stroke) in the past 6 months and you have 70% or greater narrowing in one of your carotid arteries.
If you have less than 50% narrowing, the risks outweigh the benefit of surgery.
Surgery may also be appropriate if you have had:
- One or more TIAs in the past 6 months and you have 50% to 69% narrowing.
- A series of small strokes in the past 6 months and you have 50% to 69% narrowing, and each small stroke has left you a little more disabled.
- A mild or moderate stroke in the past 6 months and you have 50% to 69% narrowing.
If you and your doctor decide that you need surgery, it is important to have the procedure done by a highly skilled surgeon at a hospital that has a good success rate in carotid endarterectomy.

Medical Information

What is carotid endarterectomy?

Carotid endarterectomy is surgery to remove plaque from one or both carotid arteries.

During a carotid endarterectomy:

A 4- to 5-inch incision is made in the neck just below the level of the jaw, exposing the narrowed carotid artery.
The blood flow through the narrowed area may need to be temporarily rerouted (shunted). Rerouting is done by placing a tube in the vessel above and below the narrowing. Blood flows around the narrowed area during the surgery.
The artery is opened and the plaque is carefully removed, often in one piece.
A vein from the leg may be sewn (grafted) on the carotid artery to widen or repair the vessel.
The shunt is removed, and the artery and skin incisions are closed.

What kinds of tests are needed before considering surgery?

Tests such as a carotid ultrasound, carotid arteriogram, or magnetic resonance angiogram (MRA) are needed before considering surgery. These tests allow your doctor to measure the plaque buildup in your carotid arteries and see how well blood flows through the narrowed area. The amount of narrowing (stenosis) usually is described as a percentage. For example, if a plaque is blocking half of the artery, the doctor may say the artery is 50% narrowed. If plaque is blocking three-quarters of the artery, the doctor may say the artery is 75% narrowed.

Some of these tests can also check the blood vessels above and below the neck. If those vessels are blocked or damaged, surgery may not be helpful because the surgeon cannot easily operate on these areas.

No test can predict accurately which plaques are likely to cause a blood clot to form and cause a TIA or stroke. But experts believe that irregular, jagged, or unstable plaques are more likely than smooth plaques to cause problems. A person who has a narrowed carotid artery that contains an irregular or jagged plaque may be at greater risk for a stroke or TIA and may benefit more from surgery.

What are the risks of carotid endarterectomy?

Risks of surgery depend on your age, your overall health, and the skill and experience of the surgeon.

The major risks associated with carotid endarterectomy are:

Stroke.
Heart attack. Most deaths that occur during a carotid endarterectomy are caused by a heart attack (myocardial infarction).
Death.
Heart and breathing difficulties, high blood pressure, infection, injury to nerves (usually causing vocal cord paralysis and problems with managing saliva and tongue movement), and bleeding within the brain.
Plaque buildup, which may redevelop as a late complication between 5 months and 13 years after surgery.

Who should not have carotid endarterectomy?

Most experts agree that carotid endarterectomy is not recommended for people who have:

TIAs that are occurring because of narrowed blood vessels in the back of the brain (vertebrobasilar arteries).
Significant disease of the arteries supplying the heart (coronary arteries) or uncontrolled high blood pressure.
Severe hardening of the arteries (atherosclerosis) that reduces blood flow in the vessels that branch off from the carotid arteries.
Other serious medical problems, such as kidney failure or heart failure, that would make surgery more risky.

Are other treatments available?

Carotid artery stenting is a procedure similar to one commonly used to open narrowed arteries in the heart. Angioplasty combined with a stent is now being done as an alternative to surgery for preventing TIA or stroke. In this procedure, a catheter is threaded through an artery in the groin and passed up to the carotid arteries. A tiny balloon is used to enlarge the narrowed portion of the artery, and a wire mesh stent is used to keep the artery open.

Carotid artery stenting may be as effective as carotid endarterectomy in preventing stroke, heart attack, and other complications in some people who have narrowed carotid arteries.^2,^3,⁴ Talk to your doctor if you would like to know if carotid artery stenting is a good option for you.

If you need more information, see the topic Stroke.

Your Information

Your choices are:

Have carotid endarterectomy.
Continue with medicines and do not have surgery.

The decision about whether to have carotid endarterectomy surgery takes into account your personal feelings and the medical facts.

**Deciding about carotid endarterectomy surgery**
Reasons to have the surgery	Reasons not to have the surgery
You have had a mild stroke or one or more TIAs in the past 6 months and you have 70% or more narrowing in your carotid artery. You have a low risk of complications from the surgery. You have had one or more TIAs in the past 6 months and you have 50% to 69% narrowing. You have had a series of small strokes in the past 6 months and you have 50% to 69% narrowing. Each small stroke has left you a little more disabled. You have had a mild or moderate stroke in the past 6 months and you have 50% to 69% narrowing. You are very worried that you might have another stroke unless you have this surgery. Are there other reasons you might want to have surgery?	You have less than 50% narrowing in the artery. Your doctor believes that medicine and controlling your other risk factors for stroke is the right therapy for you now. You have a high risk for complications from the surgery. You have had a TIA because of narrowed blood vessels in the back of your head. You have coronary artery disease or uncontrolled high blood pressure. You have severe atherosclerosis that reduces blood flow in the vessels that branch off your carotid arteries. You feel confident that your risk for stroke or TIA is low. You do not have access to a medical facility or surgeon skilled in this procedure. You want to try carotid artery stenting instead. Are there other reasons you might not want to have surgery?

These personal stories may help you make your decision.

Use the following interactive quiz to help you compare your risk of stroke with and without surgery:

Interactive Tool: What Is My Risk of Stroke With or Without Carotid Endarterectomy?

Wise Health Decision

Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about carotid endarterectomy surgery. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

My doctor believes I would benefit from the surgery.	Yes	No	Unsure
I have a low risk of complications from the surgery.	Yes	No	Unsure
I have more than 50% narrowing in my carotid artery.	Yes	No	Unsure
I have had a stroke or TIA in the last 6 months.	Yes	No	Unsure
I have symptoms related to the narrowing in my carotid artery.	Yes	No	Unsure
My doctor has performed many successful carotid endarterectomies.	Yes	No	Unsure
I have access to a large hospital that routinely performs this surgery.	Yes	No	Unsure

Use the following space to list any other important concerns you have about this decision.

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to have or not have carotid endarterectomy surgery.

Check the box below that represents your overall impression about your decision.

Leaning toward having surgery

Leaning toward NOT having surgery

Return to the topic:

References

Citations
Biller J, et al. (1998). Guidelines for carotid endarterectomy: A statement for healthcare professionals from a special writing group of the Stroke Council of the American Heart Association. Circulation, 97(5): 501-509.
Yadav JS, et al. (2004). Protected carotid-artery stenting versus endarterectomy in high-risk patients. New England Journal of Medicine, 351(15): 1493-1501.
Mas J-L, et al. (2006). Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. New England Journal of Medicine, 355(16): 1660-1671.
Brahmanandam S, et al. (2008). Clinical results of carotid artery stenting compared with carotid endarterectomy. Journal of Vascular Surgery, 47(2): 343-349.