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Endarterectomy

Endarterectomy is an operation to remove or bypass the fatty deposits, or blockage, in an artery narrowed by the buildup of fatty tissue (atherosclerosis).

Endarterectomy is the general term for the surgical removal of plaque from an artery that has become narrowed or blocked. Your arteries are normally smooth and unobstructed on the inside but they can become blocked through a process called atherosclerosis, which means hardening of the arteries. As you age, a sticky substance called plaque can build up in the walls of your arteries. Cholesterol, calcium, and fibrous tissue make up the plaque. As more plaque builds up, your arteries can narrow and stiffen. Eventually your blood vessels can no longer supply the oxygen demands of your organs or muscles, and symptoms may develop.

To perform an endarterectomy, your vascular surgeon makes an incision in the affected artery and removes the plaque contained in the artery's inner lining. This procedure leaves a wide-open artery and restores blood flow. Although sometimes other treatments may be less invasive than endarterectomy, in certain cases endarterectomy is more effective, more durable, safer, and less expensive. Sometimes endarterectomy is used in conjunction with other procedures, such as bypass or patching (widening), to open the artery and keep it open.

Physicians use endarterectomy to treat many arteries; however, the most common use is for treating blockages in the carotid arteries. Your carotid arteries are in your neck and deliver blood to your brain. Your physician may recommend endarterectomy to treat one or more of the following:

  • Carotid artery disease
  • Peripheral arterial disease, such as leg or arm artery disease
  • Renal (kidney) artery disease
  • Aortic arch conditions
  • Aortoiliac occlusive disease
  • Visceral (intestines, spleen, and liver) artery disease

  • Purpose

    Removing the fatty deposits restores normal blood flow to the part of the body supplied by the artery. An endarterectomy is performed to treat cerebrovascular disease in which there is a serious reduction of blood supply to the brain (carotid endarterectomy), or to treat peripheral vascular disease (impaired blood supply to the legs). Endarterectomy is most often performed on one of the two main arteries in the neck (the carotids) opening the narrowed arteries leading to the brain. When performed by an experienced surgeon, the practice is extremely effective, reducing the risk of stroke by up to 70%. Recent studies indicate it is effective in preventing stroke, even among those patients who had no warning signs except narrowed arteries detected by their doctors on a routine exam.

    Am I a candidate for endarterectomy?

    You may not be a candidate for an endarterectomy if you have one or more of the following:

  • Cancer
  • High blood pressure that has not been controlled by lifestyle changes or medications
  • Diabetes
  • Chest pain
  • A heart attack in the previous 6 months
  • Congestive heart failure

  • Signs of progressive brain disorders, such as Alzheimer's disease

    Carotid artery disease

    Every person has four carotid arteries (the internal and external carotids on each side of the neck) through which blood from the heart moves into the brain. If one of these arteries becomes blocked by fat and cholesterol, the patient may have a range of symptoms, including:

  • weakness in one arm, leg, half of the face, or one entire side of the body
  • numbness or tingling
  • paralysis of an arm, leg, or face
  • slurred speech
  • dizziness
  • confusion, fainting, or coma

  • Removing this fatty buildup, or bypassing a blocked segment, may restore blood flow to the brain, eliminate or decrease the symptoms, and lessen the risk of a stroke.

    Peripheral vascular disease

    When the blood vessels in the legs (and sometimes the arms) become narrowed, this can restrict blood flow and cause pain in the affected area. In severe cases, the tissue may die, requiring amputation.

    The narrowing is usually caused by buildup of fatty plaques in the vessels, often as the result of smoking, high blood pressure, or poorly-controlled diabetes mellitus. The vessels usually narrow slowly, but it's possible for a blood clot to form quickly, causing sudden severe pain in the affected leg or arm.

    Preparation

    Before surgery, the doctor pinpoints the location of the narrowed artery with an x-ray procedure called angiography. For surgery to be effective, the degree of narrowing should be at least 70%, but it should not be total. Patients undergoing angiography are given a local anesthetic, but the endarterectomy itself requires the use of a general anesthesia.

    Procedure

    Endarterectomy is a delicate operation that may require several hours. The surgeon begins by making an incision over the blocked artery and inserting a tube above and below the blockage to redirect the blood flow while the artery is opened.

    Next, the surgeon removes the fat and cholesterol buildup, along with any blood clots that have formed, with a blunt dissecting instrument. Then the surgeon bathes the clean wall in salt solution combined with heparin, an anticoagulant. Then the surgeon stitches the artery just enough so that the bypass shunt tube can be removed, and then he/she stitches the artery completely closed. After checking to make sure no blood is leaking, the surgeon next closes the skin incision with stitches.

    The operation should improve symptoms, although its long-term effects may be more limited, since arterial narrowing is rarely confined to one area of one artery. If narrowing is a problem throughout the body, arterial reconstructive surgery may be required.

    What can I expect after endarterectomy?

    Depending upon the location of your endarterectomy, you may stay overnight in the hospital for observation after surgery. For the first 24 hours, your physician will monitor your progress. In some circumstances, you may stay in the hospital for 1 to 2 days, and larger procedures requiring an abdominal incision may require 5 to 7 days of hospitalization. During your recovery, you may temporarily require fluid and nutrients through a catheter that is inserted into your vein.

    About 1 month after your procedure, your physician will usually check your blood pressure and examine your incisions in the office. However, you should call your physician immediately if you experience any of the following symptoms:

  • Weakness
  • Numbness
  • Speech impairment
  • Vision problems
  • Chest pain
  • Fever, chills, wound drainage, or redness
  • Increasing swelling or pain
  • Difficulty breathing
  • Persisting vomiting

  • If you have high cholesterol, high blood pressure, or diabetes, you should continue taking your medications unless your physician says otherwise.

    Aftercare

    After the surgery, the patient spends the first two days lying flat in bed. Patients who have had carotid endarterectomy should not bend the neck sharply during this time. Because the blood flow to the brain is now greatly increased, patients may experience a brief but severe headache, or lightheadedness. There may be a slight loss of sensation in the skin, or maybe a droop in the mouth, if any of the nerves in the neck were lightly bruised during surgery. In time, this should correct itself.

    Risks

    The amount of risk depends on the hospital, the skill of the surgeon, and the severity of underlying disease. Patients who have just had an acute stroke are at greatest risk. During carotid artery surgery, blood flow is interrupted through the artery, so that paralysis and other stroke symptoms may occur. These may resolve after surgery, or may result in permanent stroke. Paralysis is usually one-sided; other stroke symptoms may include loss of half the field of vision, loss of sensation, double vision, speech problems, and personality changes. Risks of endarterectomy to treat either carotid artery or peripheral vascular disease include:

  • reactions to anesthesia
  • bleeding
  • infection
  • blood clots