Carotid Endarterectomy

The aim is to remove the plaque that is the source of emboli or flow restriction, and so lower future stroke risk. It is offered to selected patients with symptomatic carotid stenosis and to some with severe asymptomatic stenosis after individual risk assessment. The operation is worthwhile only when the expected stroke-risk reduction outweighs the operative risk for that patient.

• Recent TIA, minor stroke or transient visual loss with significant stenosis on the relevant side
• Severe asymptomatic stenosis in selected patients after careful discussion
• Adequate fitness for surgery and anaesthesia

The recommendation reflects stenosis severity, the timing of symptoms, anatomy and medical risk, not age alone.

Medical treatment

Antiplatelet and cholesterol-lowering medication, blood-pressure control and smoking cessation are essential both before and after surgery.

Assessment and timing

Carotid ultrasound and CT or MR angiography define the narrowing, while brain imaging and neurological assessment characterise any recent stroke. When surgery follows symptoms, timing is planned carefully because the risk of a further stroke is highest in the early period.

Preparation involves carotid and brain imaging, confirmation of antiplatelet and statin therapy, anaesthetic review and a plan for blood-pressure management around the operation. Provide a full list of medicines and allergies. Because surgery after symptoms is often expedited, some of this work-up happens quickly.

Through an incision along the side of the neck, the carotid artery is temporarily clamped and opened, and the plaque is removed. The artery is closed directly or widened with a patch. A temporary shunt may be used in selected cases to maintain blood flow to the brain during clamping. The anaesthetic approach and use of a patch or shunt are tailored to the individual operation.

Most patients stay in hospital overnight for neurological and blood-pressure monitoring. Neck discomfort and tiredness are common early on and settle. Ultrasound may later monitor both the operated artery and the opposite carotid, and cardiovascular risk management continues for life. Report any new weakness, speech difficulty or visual change immediately, at any stage.

• Stroke or TIA
• Heart attack
• Bleeding or neck haematoma
• Wound infection
• Cranial nerve injury, including temporary voice or swallowing changes
• Re-narrowing of the artery
• Rare airway or swallowing problems

For appropriately selected patients, these risks are outweighed by the reduction in future stroke risk, which is the entire rationale for the operation.

Medical therapy and carotid stenting, including TCAR in selected patients, are alternatives to carotid endarterectomy. The recommended option depends on whether symptoms have occurred recently, the severity of stenosis, the patient's age and health, neck anatomy and the procedural risks associated with each approach.

The benefit of endarterectomy is not simply the removal of plaque; it is the reduction in future stroke risk for a patient whose untreated risk is sufficiently high. The consultation should therefore explain the expected absolute benefit, how soon surgery should occur after a TIA or minor stroke, and why medical treatment remains essential before and after the operation.

Temporary neck discomfort and altered sensation around the incision are common during recovery. Patients should also understand the less common risks of stroke, bleeding, cranial nerve injury and heart complications, and the plan for follow-up ultrasound. Any new neurological symptom after discharge is an emergency and requires immediate assessment through Triple Zero (000).

Yarra Vascular Surgeons provides timely carotid assessment, imaging and open carotid surgery, with decisions grounded in stenosis severity, recent neurological symptoms, anatomy and the expected benefit of intervention for each patient.

Carotid endarterectomy remains an important treatment for selected symptomatic and severe asymptomatic carotid disease. Sudden facial droop, arm weakness or speech difficulty is an emergency: call Triple Zero (000). For recent TIA symptoms, seek urgent referral.