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Date issued: November 2023

Review date: November 2025 

Ref: A-92/JW/Vascular/Carotid disease v4

PDF: Carotid disease.pdf [pdf] 330KB

1. What is Carotid Disease?

The carotid artery in the neck provides the principal blood supply to the brain. The artery (common carotid artery) runs up the side of the neck and divides into two branches just below the angle of the jaw. One branch supplies the face (external carotid artery). The other branch passes directly to the brain with no other branches in the neck (internal carotid artery).

Arteries tend to narrow where they divide. Narrowing at the carotid bifurcation (division of common carotid artery) may directly restrict the blood supply to the brain. Additionally and more importantly, debris stuck to the narrow area may break off and fly into the brain or into the artery to the eye.

2. How is carotid disease detected clinically?

Debris flying into the brain may produce a mini-stroke. A mini-stroke (transient ischaemic attack or TIA) is a small stroke which usually lasts less than 24 hours. It affects one side of the body only. Sometimes, there is transient blindness (Amaurosis Fugax) affecting one eye usually lasting only a few seconds. Sometimes, the speech centre in the brain is affected leading to either jumbled speech or complete loss of speech. A key feature of a TIA is that it recovers completely within 24 hours.

The right side of the brain supplies the left side of the body and vice versa. Symptoms of weakness are therefore found on the ‘wrong’ side in relation to the arterial narrowing. Transient blindness by contrast affects the same side, because debris passes directly into the back of the same eye.

When TIA symptoms are associated with a very tight narrowing of the artery to the brain, there is a high risk of major stroke. The risk of stroke is greatest during the first 3-4 months after the TIA. When the narrowing is less severe, or when there are no symptoms, the risk of stroke is much lower.

There are several illnesses that may seem very much like TIA's. These include migraine, epileptic fits or seizures, a low blood sugar, faint and changes in heart rhythm. TIA's do not usually cause blackouts, fainting or loss of consciousness. These other illnesses need different treatments and it is important that people with TIA symptoms are seen by a specialist to find out the cause of the trouble.

3. What tests can be used to detect carotid disease?

Sometimes, narrowing can be detected with a stethoscope if there is turbulence of blood flow in the artery and a squeaking or rushing noise.

Ultrasound is the main way of diagnosing carotid disease. The ultrasound image may show narrowing on screen where the carotid bifurcation is usually easily seen. Ultrasound can also be used to study the speed of blood flow at the point of narrowing. Red cells have to speed up to get through the narrowed segment and the increase in flow velocity is determined by the degree of narrowing.

A carotid angiogram is an X-ray of the circulation to the brain taken by injecting dye (contrast) into the carotid artery. A catheter is threaded into the artery from puncture of the femoral artery at groin level. This procedure is performed under local anaesthetic.

Some patients will have a scan of the brain (CT or MRI scan). This scan can detect signs of damage to the brain and rule out other causes of your symptoms.

4. Who is at risk?

TIA’s affect those of increasing age (usually over 60 years), and are more common in men than women. They are much more likely in smokers, those with high blood pressure and those with high cholesterol (hyperlipidaemia).

5. Do I need treatment?

The combination of TIA, or amaurosis fugax and tight narrowing of the carotid artery put you at risk of major stroke.

Some Surgeons recommend treatment of a tight narrowing on its own, in the absence of symptoms. In particular, Cardiac Surgeons often insist on treatment of the carotid stenosis prior to heart bypass surgery.

If surgery is recommended, it should be done as soon as possible after TIA symptoms because this is the time of greatest risk for a major stroke.  If treatment is delayed, or if you decide not to have an operation, there is a significantly increased risk of major stroke during the following 12 months but particularly during the following 3 months.

The aim of surgical treatment is to reduce the risk of major stroke posed by the tight narrowing in the neck. The risk of major stroke is reduced from approximately 1 in 5 to 1 in 25.

6. What does treatment involve?

There are two lines of treatment; medication and surgery.

All patients will be recommended to take an Aspirin-like drug. There are several available including aspirin, dipyridamole and clopidogrel. Your Surgeon or GP will discuss the options with you. Some of these drugs can cause indigestion and are contra-indicated in those with known peptic ulcer disease (gastric or duodenal ulcer).

Carotid endarterectomy is an operation to unblock the narrowed carotid artery. The artery is carefully exposed through an incision running vertically in the side of the neck. The artery is opened, cleared of the debris and carefully sewn up again. The operation is usually done under local anaesthetic. During the operation, if you become uncomfortable, the Surgeon will inject more local anaesthetic. You will also be given some sedation and, as a result, you may not be very aware of the operation at all.

7. Coming into hospital

Please bring with you all the medications that you are currently taking. You will be admitted to your bed by one of the nurses who will also complete your nursing record.

You will be visited by the Surgeon who will be performing your operation, and also by the doctor who will give you the anaesthetic. Your operation, in exceptional circumstances, may be performed by a Vascular Consultant who did not assess you in clinic.

Physiotherapists and Intensive or High Dependency Care staff may also visit, to give you information about your postoperative care. If you have any remaining questions about the operation, please do not hesitate to ask the doctors.

8. The Operation

You will have a cut running from near the angle of your jaw towards your breastbone. The incision is usually 7-10cm (between 2 ½ “and 4”) in length.

The carotid artery is displayed. After clamping of the branches of the artery, it is opened longitudinally and the narrowing carefully removed.

When the inside of the artery has been cleared, it is closed with very fine stitches, either directly, or sometimes with a synthetic patch to prevent narrowing.

The wound is closed with either a stitch under the skin that dissolves or by clips that will need to be removed about 5 days after the surgery.

To protect the brain from interruption to its blood supply, while it is clamped, a shunt (narrow plastic tube) is sometimes used to maintain blood flow. The shunt lies in a loop outside the artery, passing into the artery above and below at each end of the incision in the artery.

9. After the Treatment

You will usually be taken to the Vascular Ward after your operation so that we can monitor your progress closely.

Local anaesthetics are used to numb the skin so there should be little discomfort.

Following this sort of surgery, you are unlikely to feel sick and you should be able to eat and drink again within a few hours.

Blood transfusion is rarely required.

Your mobility will return to normal more or less immediately.

There is often some swelling in the neck, but this settles within 7 to 10 days.

The incision, although initially very visible, will subside to become virtually invisible within 2-3 months.

10. Going home

Most people stay in hospital for 1 night after carotid endarterectomy and go home the next day.

If your stitches or clips are the type that need removing, we will arrange for your GP practice or district nurse to remove them and check your wound.

Regular exercise such as a short walk combined with rest is recommended to provide a gradual return to normal activity.

Driving : You will be able to drive when you are can perform an emergency stop safely. This will normally be 2 to 3 weeks after surgery, but if in doubt check with your own doctor.

Bathing : Once your wound is dry you may bathe or shower as normal. This will normally be before you leave hospital.

Work : If this applies to you, you should be able to return to work within 2 to 3 weeks of surgery. We will provide you with a sick note but if you need longer off work, please see your GP.

Lifting : There are no limitations in this area.

Medicines : You will usually be sent home on a small dose of aspirin or similar if you were not already taking it. This makes the blood less sticky. If you are allergic to aspirin, or if it upsets your tummy, an alternative drug may be prescribed. No other changes to your medication are required.

11. Complications

• Chest infections: These can occur following this type of surgery, particularly in smokers, and may require treatment with antibiotics and physiotherapy.
• Wound infection: Wounds sometimes become infected and this may need treatment with antibiotics. Bad infections are rare.
• Fluid leak from wound: Occasionally the wound can bleed or bleeding beneath the wound will cause swelling. Usually the swelling will settle on its own, but occasionally the wound may need further surgical attention.
• Nerve injuries : These are uncommon. A nerve picking up skin sensation may occasionally be severed leading to loss of skin sensation somewhere in the neck. The Vagus Nerve provides a branch to the voice box (larynx). Damage to it, which happens only very rarely, leads to a hoarse voice. The Hypoglossal Nerve supplies the muscles of the tongue. Damage to it, again rare, will affect speech slightly by reducing the tongue’s mobility. The Facial Nerve supplies the muscles of the face. Damage to its lowest branch may lead to impaired movement of muscles around the lower jaw and neck. Again, this is rare.
• Stroke : A small number of people, between 1 and 3 in 100, having carotid endarterectomy will have a stroke during the operation. All possible precautions will be taken to prevent this eventuality.
• Other Major Complications: As with any major operation, there is a small risk of you having a medical complication such as a heart attack, kidney failure, chest problems or infection in the wound. Each of these is rare, but overall it does mean that some patients may have a fatal complication from their operation. For most patients this risk is about 1% - in other words, 99 in every 100 patients will make a full recovery from the operation.
• If your risk of a major complication is higher than this, usually because you already have a serious medical problem, then your Surgeon will discuss this with you. It is important to remember that your Surgeon will only recommend treatment if he or she believes that the threat of stroke without operation is much higher than the threat posed by the operation itself.

12. What can I do to help myself?

If you are a smoker, you should make a determined effort to stop completely. Continued smoking will cause further damage to your arteries and increases the risks of heart attacks, strokes and problems with the circulation in your legs. It is also likely to jeopardise the success of any surgical operation carried out and to make recovery more difficult.

Why not take this opportunity to consult your own doctor or the practice nursing staff to seek professional help in giving up the addiction?

Further help is available locally from the Smoking Advice Service Tel: 0300 123 1044 

General health measures such as reducing weight, a low fat diet and regular exercise are also important.

13. Is treatment successful?

Carotid endarterectomy reduces the threat of stroke from about 1 in 5 to 1 in 25. It normally provides very good long-term results.

Contact details

Vascular Surgical Unit

Surgical Directorate

Plymouth Hospitals NHS Trust

Derriford Hospital

PL6 8DH

Tel 01752 202082

Consultant Vascular Surgeon and Lead Clinician

Mr Devender Mittapalli

Secretary: 01752 431822

Consultant Vascular and Transplant Surgeon

Mr Jamie Barwell

Secretary: 01752 431822

Consultant Vascular Surgeon

Surgeon Commander Cris Parry RN

Secretary: 01752 431822

Consultant Vascular Surgeon

Miss Catherine Western

Secretary: 01752 431805

Consultant Vascular Surgeon

Lt Col Robert Faulconer

Secretary: 01752 431805

Consultant Vascular Surgeon

Mr Hashem Barakat

Secretary: 01752 431822

Vascular Scientists

• Mrs J George
• Mr A Ellison
• Mr R Craven

01752 439228

Vascular Nurse Specialist

Mr Alan Elstone

01752 431805

Matron

Judy Frame

01752 431847