The Operation
This involves an incision on the neck to display the Carotid Artery which is then clamped from above and below and opened. Narrowing from atheroma is then removed (endarterectomy) and when the artery wall inside is smooth the artery is closed with sutures or with the use of a patch in the wound and then sutured from the patch to the artery wall. It can be performed under regional or general anaesthesia. In some cases a plastic tube (shunt) can be placed in the proximal common carotid artery around the wound and then into the distal internal carotid artery to maintain cerebral blood flow. The operation generally takes about two hours and is performed by specialist vascular surgeons. The patient needs a few days in hospital. Recovery is swift apart from some stiffness of the neck and a few weeks off work. Surgery to the other side might be required. Carotid disease is very significantly associated with diabetes, cigarette smoking and coronary artery disease.

The Indications for Surgery
The aim of the surgery is to prevent the patient having a significant stroke. Many of these patients are found by having a temporary stroke (TIA) e.g. loss of vision or speech or weakness in the hand that lasts only a few moments or minutes. Some have had a minor stroke and have recovered. Some have been found to have narrowed carotid arteries when being investigated for other vascular or cardiac problems.

Not all strokes are due to Carotid disease but a large number are and it is an important diagnosis for all doctors to think of and look for. Investigation is by arterial ultrasound and then referral to a vascular surgeon. Narrowing of over 70 or 80% is generally thought fit for treatment i.e. the risks of treatment are less than the risks of medical management.

CEA is of Proven Benefit
In the later 1980’s and 1990’s a series of trials established the proven benefit of this operation e.g. NASCET, ACAS and hundreds of publications which followed. It is the only operation proven to be of benefit in vascular surgery. It is probably one of the most studied operations in the history of surgery. At the time of these trials the stroke rate from surgery was around 7%. It is now below 3% and sometimes lower than that.

Carotid Angioplasty
A newer alternative is Carotid Angioplasty and stenting (CAS) which has the advantage of a percutaneous procedure and avoidance of neck incision and the various wound issues related to that. The disadvantage is that a stent needs to be pushed through the stenosis and expanded. The stent sits in an area of fine movement. This procedure was popularised in the early part of this millennium as a minimally invasive procedure which could be safer than surgery. It has a place, but in fact overall it has been found to be more dangerous in the older sicker patient and probably less durable.

CEA Overview
Carotid Angioplasty (CAS) having been around for 20 years still remains controversial and of limited application. During that time Carotid surgery has progressively been improved and is undergoing a mild resurgence. Both of these procedures are less common now than they used to be due to the widespread use of multi-drug anti-hypertensive treatment, cholesterol lowering lipid modifying agents, and in particular the stronger anti-platelet drugs such as Clopidogrel. (Plavix, Iscover)

The compelling argument for endovascular treatment of aortic conditions in contrast to the very large surgery required seems less applicable in carotid surgery where the operation is comparatively localised.