Carotid Endarterectomy

Pre and Post Hospital Instructions

Your Body

Dr. Cohn, your vascular surgeon, has recommended surgical intervention for your carotid artery stenosis.  This type of surgery is called a Carotid Endarterectomy.

The main goal of this surgery is to reduce the risk of stroke. He will accomplish this by removing a blockage that's in one of the arteries in your neck.

Carotid arteries
You have a set on each side of your neck. They're made of up 3 sections:

·         Common carotid carries blood into the neck

·         External carotid carries blood to the muscles and other parts of your face

·         Internal carotid carries blood to your brain

Why is the problem in your neck and not somewhere else in your body?
The vessel starts as a single artery and then branches off. This is where most people have a blocked artery.

The problem is caused by atherosclerosis (hardening of the arteries). When you eat high-fat and high-cholesterol foods, bits of fat and cholesterol go into your bloodstream. These combine with tissue, calcium, and clumps of blood (clots) to form plaque. Big pieces of plaque usually get stuck in the carotid artery. This creates different degrees of blockage (stenosis). Stenosis is the amount (degree) to which your carotid arteries are blocked. Your doctor may talk about this as a percentage.

If you have 75% blockage, that means it's 3/4 blocked. So it's nearly closed.

Blocked Arteries

A blockage in your artery can be extremely dangerous.

·         A piece of plaque or a blood clot can break off and travel to the brain.

·         The blockage may cut off the blood supply to a part of the brain.

Either one of these things can cause a few big problems, including:

·         TIA (transient ischemic attack)

·         Stroke

With either TIA or stroke, the signs are very similar. If you have any of these signs, call 911 or go to the emergency room right away.

Signs of TIA or stroke include:

·         Weakness

·         Numbness

·         A tingling sensation on one side of your body

·         Confusion

·         Problems speaking or slurred speech

·         Dizziness or loss of balance

·         You can't control the movements in your arms or legs, or you can't feel your arms or legs

·         You lose sight in one eye, like a shade or curtain coming down over your eye

Important differences between TIA and stroke

TIA:

·         Lasts anywhere from a few minutes to several hours

·         There may be no obvious, permanent brain damage

Stroke:

·         Lasts 24 hours or longer

·         There may be permanent brain damage

Before the Procedure

The weeks or months before surgery
It's very important for Dr. Cohn to learn about your overall health and health history.

Tell Dr. Cohn if:

·         You've had any procedures, including radiation treatments, to the head or neck

·         You're allergic to any foods (like shellfish), materials (like latex), or drugs (like penicillin)

·         You or anyone in your family has ever had a bad reaction to anesthesia

For your safety, it's important to make a list of everything you take. This includes:

·         All prescription medications

·         Any other medicine (like aspirin, Advil®, or Motrin®)

·         Immunosuppressants, such as cancer drugs or steroids

·         Supplements (like Echinacea, Ginkgo biloba, or fish oil)

·         Vitamins (especially vitamin C and vitamin E)

Some medications and herbal supplements can put you at a higher risk for bleeding or blood clots if you take them right up to the day of surgery.

Blood-thinning medication
If you take a blood-thinning drug like warfarin (Coumadin®), or a drug called Plavix®, you'll need to talk to Dr. Cohn to find out if you should stop it before the surgery.  Do not stop these medications on your own.

Smoking
If you smoke or use anything with nicotine in it (including nicotine patches or gum), make sure Dr. Cohn knows this. Nicotine products may cause problems with healing and may cause your arteries to become blocked again after the procedure. Your doctor will likely talk to you about quitting smoking in the weeks before surgery. If you're interested in quitting, talk to Dr. Cohn about what options are available.

For a complete list of what to stop taking, and when, ask Dr. Cohn.
There are some things you may need to continue. For example, they may want you to keep taking aspirin, up to the procedure.

Partner in care
It's also a good idea to ask a family member or a friend to be there with you for comfort and support. Think of this person as your partner in care. Doctors and nurses like to have one "go to" person for all communication. He or she should be able to speak up for you, ask questions, and give information about your health. Be sure to introduce this person to your doctors and your nurses so they know it's OK to share your health information with them.

The night before your procedure
You'll probably get a list of instructions telling you what to do.

·         One very important thing to remember is NOT to eat or drink anything after midnight the night before your procedure.

·         If there's anything in your stomach and you throw up during the procedure, it can be very dangerous. So make sure your stomach is EMPTY, or your procedure may need to be rescheduled.

·         If Dr. Cohn tells you to take aspirin or any of your other medications that morning, just take them with a sip of water.

·         For men, your doctor may or may not ask you to shave before the procedure. It just depends on how he does things.

Pack a small bag to bring with you on the day of your procedure.
You'll want to have things like:

·         Dentures, if you use them

·         Eyeglasses, for reading or watching TV

·         Hearing aids, even if you only need them in one ear

·         A list of your regular medications, if you take any

You'll have to stay overnight, and it'll be really helpful to have these things with you.

Your Procedure-Carotid Endarterectomy

Before the procedure begins

·         An IV will be placed in your hand or your arm. This is so they can give you antibiotics, medication, and fluids.

·         You'll be connected to monitors that measure your blood pressure, heart rate, and the amount of oxygen in your blood.

·         In some cases, small electrodes may be placed on your head, arms, and legs. This allows them to "watch" your brain during the procedure. But they're not always needed.

·         You'll get a little bit of medicine through your IV to help you relax and fall asleep.

Anesthesia

·         General anesthesia—In some cases, they may use general anesthesia, which puts you into a deep sleep. Dr. Cohn can tell you if this may be right for you.

·         Local-regional anesthesia—With this, they'll use nerve blocks to numb your neck. You'll also get some medicine to keep you relaxed. But with local-regional anesthesia, you won't be completely asleep, so they can talk with you and ask questions during the procedure.

If you want to know what kind of anesthesia your doctor's going to use, be sure to ask about this.

When everything is ready, the procedure can begin.
It can take anywhere from 1 to 2 hours, maybe longer.

If you have blocked arteries on both sides, Dr. Cohn will only operate on one side at a time.

1.    He'll start by making a cut on the neck.

2.    He'll find the part of the artery that has the blockage.

3.    He may give you some blood-thinning medication through your IV.

4.    Clamps will be placed above and below the blockage.

Placing a shunt
In some cases, they may also need to put a small device, called a shunt, in the artery. Because even though blood keeps flowing on the other side of your neck, they may want to get more blood to your brain during the procedure.

Removing the plaque

1.    A small cut will be made in your artery.

2.    Your doctor will remove the plaque, and if you want he will save it for you.

3.    After the artery is clear, he'll take out the shunt (if one was placed).

4.    He'll close the artery with a special patch or stitches.

5.    The clamps are removed and blood flows through this artery again.

6.    Your neck is closed with dissolvable stitches, and the cut is covered with a bandage.

7.    A small drain may be placed to help drain fluid.

Your next stop is the recovery room.

After the procedure

After the procedure, expect to feel groggy and a little out of it when you wake up.

In recovery
You may be hooked up to some monitors and your IV for medication and fluids. If you feel sick to your stomach or have the chills, just ask your nurse to help you get comfortable.

During the first few hours, they'll want you to eat and drink. You'll most likely be up and walking before you leave.

Some people stay overnight in the hospital, others may stay 2 nights. Either way, once your doctor thinks you're ready, you can go home. Just make sure you have someone to drive you home. Don't even think about driving yourself for the first few days. It's just not safe.

Risks Associated with Carotid Endarterectomy

After a carotid endarterectomy, your quality of life may improve, and you'll have a smaller risk of stroke or TIA.

Like any procedure, there are some risks. Understanding what's involved is an important part of any procedure. If you have any questions about how these risks relate to you, please ask your doctor. This will cover 8 risks, but there are some very unusual risks that will not be covered. So please do not consider this list complete.

1. There is a risk of stroke or TIA both during and after the procedure. While the risk is small, it is possible to die from a stroke.
A stroke happens when the blood supply to the brain gets cut off. There is a small chance this could happen during or after your procedure.

Signs of stroke include:

• Weakness or numbness on one side of the body (in the face, upper body, or lower body)
• Any mental confusion or problems speaking
• Trouble seeing in one eye
• Dizziness or loss of balance
• A severe headache

If you ever feel any of these things, call or go to the emergency room right away.

Having a stroke during or after the procedure is more common if you are not following your doctor's instructions about:

·         Smoking

·         Diet

·         High blood pressure

If you have any questions about the risk of stroke, please talk with your doctor.

2. There is a risk blood may collect in the area the procedure was done. If this happens, a large bruise (hematoma) can form. In some cases, another procedure may be needed to drain blood from this area.
After a carotid endarterectomy, it's possible for blood to collect in the area where the surgery was performed. If this happens, a large bruise (hematoma) may form.

Signs of a hematoma include:

• Severe neck pain
• Trouble swallowing
• Problems breathing

If you have any of these, call your doctor right away. You may need a procedure to drain the blood from this area.

3. There is a risk of injury to the nerves in your neck, causing difficulty swallowing, weakness in your face or neck, or hoarseness (where you lose your voice). In some cases, these feelings may be permanent. Rarely, surgery may be needed to repair a nerve injury.
During the procedure, there is a chance one of the nerves in your neck can be overstretched or pulled too far. If this happens, you may:

• Have trouble swallowing
• Feel weakness or tingling in your face and neck, usually on the side the procedure was done
• Lose your voice and become hoarse

Sometimes, these feelings go away on their own. In rare cases, these can be permanent. If possible, another surgery may be needed to repair any permanent injuries.

4. There is a small risk of infection. Most of the time, antibiotics alone can get rid of an infection. But in rare cases, special treatment will be needed.
Although your doctor will take great care to prevent it, you may get an infection in the area where the procedure was done, or in other parts of your body (like in your lungs or bladder). Signs of infection include:

• Redness
• Swelling
• Fluid draining from the area surgery was done
• Pain that gets worse
• A high fever or chills.

If you feel any of these things, call your doctor right away. Most of the time, antibiotics alone can get rid of an infection. But in very rare cases, you may need to be admitted to the hospital for surgery or other treatments.

5. While it's rare, there is a chance of high or low blood pressure after this procedure. If there are problems with your blood pressure, medications may be used to treat this.
You could have new problems with high blood pressure or low blood pressure. If this happens, new medications, or changes to medications you're already taking, may be needed to help manage your blood pressure.

6. There is a risk of bad or allergic reactions to the anesthesia, medications, or materials that are used. While it's very rare, you can die from a serious reaction.
Some people may have bad reactions to anesthesia. For example, they may feel sick to their stomach or throw up after their procedure. But an allergic reaction happens when your body tries to get rid of something it doesn't want. It's your body's response that can be serious. Signs can include:

• Dizziness
• Swelling
• Rash
• Trouble breathing

Your healthcare team is trained and ready to respond to allergic reactions. In rare cases, people can die. If you've ever had an allergic reaction, or know you're allergic to any drugs, foods, or materials (like latex), please let your doctors know. And let them know if you or anyone in your family has ever had a serious reaction to anesthesia.

7. There is a chance of restenosis, which means your arteries could become blocked again. If this happens, another procedure may be needed.
Most of the time, a carotid endarterectomy works to clear the plaque from your arteries. But during the first year after surgery, it's possible for the arteries to become blocked again (restenosis). This can happen if:

• You continue to smoke
• There are problems with healing

If restenosis does occur, your doctor will talk with you about the best plan of action. In rare cases, another procedure may be recommended.

8.    There is an extremely small risk of a heart attack or death.<