Stroke Prevention Surgery
Carotid Surgery
Specialist assessment and carotid endarterectomy for selected patients with significant carotid artery disease, with treatment aimed at reducing future stroke risk.
Removing plaque from a narrowed carotid artery
Carotid endarterectomy is an open operation that removes atherosclerotic plaque from the carotid artery in selected patients where the expected reduction in stroke risk outweighs the risks of surgery.
Understanding Carotid Surgery
Surgery to reduce the risk of stroke
The carotid arteries are the major blood vessels in the neck supplying blood to the brain. Atherosclerosis can cause plaque to build up within these arteries and narrow the channel.
In some patients, material associated with the plaque can contribute to a transient ischaemic attack or stroke. When clinically appropriate, carotid endarterectomy removes the diseased plaque from inside the artery.
Surgery is not appropriate for every carotid narrowing. The decision depends on whether symptoms have occurred, the degree of stenosis, imaging findings, overall health and the balance between operative risk and expected stroke prevention.
Assessment may be required after
- Transient weakness or numbness on one side
- Temporary difficulty speaking
- Temporary loss or disturbance of vision
- A transient ischaemic attack
- A stroke with carotid disease identified
- Significant carotid stenosis found on imaging
Treatment is about future risk
Carotid endarterectomy does not reverse neurological injury that has already occurred. Its purpose is to reduce the risk of a further stroke in appropriately selected patients.
Why Carotid Endarterectomy?
Removing the source of dangerous carotid plaque
Carotid artery disease can increase stroke risk when plaque within the artery causes significant narrowing or releases material towards the brain.
During carotid endarterectomy, the affected artery is opened and the plaque is removed directly. The artery is then repaired to restore a smooth channel for blood flow.
The Operation
How carotid endarterectomy is performed
The precise operative technique is individualised, but the central principle is removal of the plaque causing the carotid narrowing.
Carotid Exposure
An incision is made in the neck to carefully expose the affected carotid artery.
Artery Opened
The carotid artery is controlled and opened so the diseased inner lining can be treated.
Plaque Removed
The atherosclerotic plaque causing the narrowing is carefully removed from the artery.
Artery Repaired
The artery is closed, often using a patch where appropriate, and blood flow is restored.
Symptomatic Carotid Disease
Timing matters after a TIA or stroke
When significant carotid stenosis is associated with recent neurological symptoms, specialist assessment is time-sensitive because the risk of another event may be greatest early after the first episode.
Patients are assessed to confirm that the carotid disease is relevant to the neurological event and that surgery offers a favourable balance of benefit and risk.
Symptoms requiring urgent medical assessment
- Facial weakness
- Weakness or numbness of one arm or leg
- Difficulty speaking or understanding speech
- Sudden loss or disturbance of vision
- New neurological symptoms that resolve again
Before Surgery
Carotid imaging guides treatment decisions
Assessment starts by establishing whether neurological symptoms are consistent with carotid artery disease and measuring the severity of narrowing.
Carotid duplex ultrasound is commonly used to assess stenosis and blood flow. Further vascular imaging may be used when additional anatomical information is required.
The patient's general health, medication, blood pressure and cardiovascular risk are also considered before recommending an operation.
Clinical Assessment
Neurological symptoms, timing and vascular risk factors are reviewed.
Carotid Ultrasound
Duplex imaging assesses blood flow and the severity of carotid stenosis.
Treatment Planning
Surgery, medical treatment or another approach is considered according to individual risk and anatomy.
Treatment Options
Carotid endarterectomy or stenting?
Carotid endarterectomy remains an important surgical treatment for suitable patients. Carotid stenting may be considered in selected circumstances.
Carotid Endarterectomy
The carotid artery is exposed through an incision in the neck and the atherosclerotic plaque is removed directly from within the vessel.
Carotid Artery Stenting
Carotid stenting is an endovascular alternative that may be appropriate for selected patients depending on anatomy, previous treatment, medical circumstances and procedural risk.
Preparing for Surgery
Medical treatment remains important alongside surgery
Carotid endarterectomy addresses a particular carotid plaque, but atherosclerosis is a wider cardiovascular condition.
Medication and management of cardiovascular risk therefore remain important before and after surgery. Medication should only be changed according to advice from the treating team.
Pre-operative assessment also considers anaesthetic suitability, blood pressure, cardiac history and other medical conditions.
Pre-operative assessment may include
- Review of carotid imaging
- Review of neurological symptoms
- Blood pressure assessment
- Medication review
- Blood tests
- ECG where appropriate
- Anaesthetic assessment
After the Operation
Recovery after carotid endarterectomy
Following surgery, blood pressure, neurological function and the neck wound are monitored closely.
Some bruising, swelling or discomfort around the incision can occur during the early recovery period.
Activity is gradually increased and individual advice is provided regarding wound care, work, driving and return to more strenuous activity.
Cardiovascular medication and risk-factor management remain important after surgery.
Follow-up may include
- Wound review
- Blood pressure monitoring
- Neurological assessment
- Medication review
- Cardiovascular risk-factor management
- Further carotid surveillance where appropriate
Treatment Considerations
The risks of surgery are balanced against stroke prevention
Carotid endarterectomy is performed to reduce future stroke risk, but the operation itself carries potential complications that are discussed before treatment.
Stroke
Stroke is an important potential complication of carotid surgery, although the operation is performed to reduce longer-term stroke risk.
Bleeding
Bleeding or a collection of blood in the neck can occur and may occasionally require further treatment.
Cranial Nerve Injury
Nerves close to the carotid artery can occasionally be affected, causing temporary or persistent changes in movement or sensation.
Wound Infection
Infection of the neck wound is uncommon but can occur after surgery.
Cardiovascular Complications
As with major vascular surgery, cardiac and other medical risks are considered during pre-operative assessment.
Re-Narrowing
The carotid artery can occasionally narrow again over time and may require further surveillance.
Specialist Carotid Care
Consultant-led assessment and carotid surgery
Mr Shanka Benaragama is a Consultant Vascular and Endovascular Surgeon at Royal Free London and University College London Hospitals.
His specialist practice includes carotid disease and carotid endarterectomy, alongside wider open and endovascular vascular surgery.
Carotid care includes
- Assessment of carotid stenosis
- Review following TIA or stroke
- Interpretation of carotid imaging
- Carotid endarterectomy
- Consideration of endovascular alternatives
- Cardiovascular risk management alongside treatment
Stroke & TIA Symptoms
New neurological symptoms require emergency assessment
Call 999 immediately for sudden facial weakness, weakness or numbness on one side of the body, difficulty speaking, sudden loss of vision or other new symptoms of stroke. This remains an emergency even if the symptoms improve or disappear. Do not wait for a routine private consultation.
Frequently Asked Questions
Carotid surgery questions
What is a carotid endarterectomy?
Carotid endarterectomy is an operation in which the carotid artery is opened and atherosclerotic plaque is removed to reduce the risk of future stroke in appropriately selected patients.
Why would I need carotid surgery?
Surgery may be considered when significant carotid narrowing is associated with a level of future stroke risk for which the expected benefit of intervention outweighs the operative risks.
Does carotid endarterectomy treat a stroke that has already happened?
No. The purpose of carotid endarterectomy is primarily to reduce the risk of a future stroke. It does not reverse established brain injury from a previous stroke.
How is carotid narrowing assessed?
Carotid duplex ultrasound is commonly used to assess the severity of narrowing. Additional vascular imaging may be required depending on the clinical situation.
Is carotid surgery urgent after a TIA?
Significant symptomatic carotid disease can require time-sensitive specialist assessment because the risk of another neurological event may be greatest soon after a TIA or stroke.
What happens during the operation?
An incision is made in the neck, the carotid artery is opened and the plaque is removed. The artery is then repaired, often with a patch where appropriate, before blood flow is restored.
What are the main risks?
Potential complications include stroke, bleeding, wound problems, nerve injury and cardiovascular complications. Individual risk is discussed before surgery.
Can carotid stenting be used instead?
Carotid stenting may be considered for selected patients depending on individual anatomy, previous treatment and procedural risk. It is not automatically preferable to carotid endarterectomy.
Carotid Surgery Consultation
Request a specialist carotid consultation
If carotid artery narrowing has been identified on a scan, or you have been advised that carotid surgery may be required, please contact the practice for a specialist vascular opinion.
Email to Request a Consultation → benaragama.admin@lips.org.uk