The carotid artery (carotids) is a large paired vessel that together with smaller vertebral arteries is responsible for feeding the brain. Its blockage leads to cerebrovascular insufficiency with the risk of a subsequent stroke, and the presence of protrusion of the wall (aneurysm) threatens to rupture.
Carotid artery surgery is mainly indicated for patients suffering from stenosis of the vessel and is to ensure adequate blood supply to the brain. The carotid arteries are the largest and most important vessels that supply blood to the brain which is very sensitive to oxygen deficiency. Even a little narrowing of these arteries can cause symptoms of damage to the nervous tissue and is fraught with a stroke and even the patient’s death.
The areas vascular surgeons pay great attention to are the bifurcation area of the common carotid and the internal carotid artery. These are the areas that most often undergo structural changes, and therefore they become the object for surgical treatment.
Stroke (cerebral infarction) is one of the most dangerous diseases of the vascular system and the brain, the prevalence of which has become rampant in recent decades. The main cause of cerebral infarction is atherosclerosis which causes a critical narrowing of the arterial lumen. Of course, therapeutic approaches have been developed in the treatment of pathology, but, as shown by the results of large-scale studies, none of the conservative methods can give such a result as surgery.
Disorders in the blood flow in the brain do not pass without leaving a trace. There are often serious consequences that make the patient disabled, and it is not always possible to restore the lost brain functions even through surgery. In connection with this circumstance, surgical treatment to prevent vascular accidents of the brain, that is, before the nervous system suffers, is of great importance.
Surgical prevention of carotid stenosis significantly reduces the probability of acute circulatory disorders, normalizes blood delivery to the brain, improves patients’ well-being, and after a stroke enables a more successful rehabilitation.
The only treatment option for severe stenosis, carotid aneurysm is a surgical one. Let’s consider the main types of carotid artery surgery, their advantages and disadvantages, peculiarities of the preoperative preparation, rehabilitation period and possible risks.
Atherosclerosis is called one of the main reasons for the narrowing of the arterial lumen. The disease occurs as a result of age-related changes, excessive consumption of fatty foods and metabolic disorders. Due to the influence of these factors, atherosclerotic plaques begin to build up on the walls of the vessels. They narrow or completely block their lumen, and thereby significantly impede or stop blood circulation. Carotid stenosis can occur under the influence of other pathological causes and irritants. These include:
Carotid stenosis is more common in men. However, the risk of developing the disease exists in both sexes, in patients with a prior history of one of the diseases described above or exposed to several of these factors.
In the initial stages, when the vessel lumen is narrowed slightly, stenosis practically does not declare itself. An asymptomatic period can sometimes last more than a year. All this time the person has no idea about the existing pathology.
The first alarming symptom of stenosis of one of the carotid arteries is a periodically occurring ischemic attack or the occurrence of a microstroke. At such moments, the blood supply to certain structures of the brain decreases for a short period of time, their oxygen starvation occurs and the following symptoms begin to bother the patient:
Signs of ischemic attacks intensely disturb for 15–25 minutes, then they disappear and the lost functions come to normal after an hour. With a microstroke, severe symptoms in the form of paralysis and impaired cerebral activity may become protracted and lead to irreversible processes. To prevent this, it is necessary to consult a doctor for emergency treatment at the first signs of these dangerous diseases, indicative of carotid artery stenosis.
Considering the peculiarity of the symptoms, the narrowing of the carotid arteries is diagnosed at the late stage of the disease. Depending on the patient’s condition and complaints, a neurologist or a vascular surgeon performs a visual examination.
The specialist assesses the state of the vessels above the carotid arteries, feels and listens to them in order to determine the degree of blood flow by the characteristic noise. After that, the patient may need the following examinations:
Indications for surgery for carotid stenosis are:
Surgery is prohibited in some cases. They are:
In addition, a contraindication for stent insertion is allergy to the materials from which it is made.
There are many methods of surgical intervention on the carotid arteries. All of them belong to two groups:
The choice of the type of surgery depends on the location of the pathological area, the patient’s state of health, chronic diseases, a stroke and a heart attack in past history. The main indications for surgery are cerebral blood flow disorders, the risk of getting a stroke caused by: narrowing of the vessel lumen (stenosis); carotid artery occlusion; aneurysm; pathological tortuosity of blood vessels.
Carotid endarterectomy is considered to be the “gold standard” for the treatment of carotid atherosclerosis. The indications for surgery are:
Before the plaque is removed, all patients undergo a comprehensive medical examination, which includes:
To reduce the risk of complications, it is advisable to prepare your body for surgery:
There are several techniques to perform carotid endarterectomy:
The advantages of endarterectomy are: physiological compatibility (restoration of blood flow without changing the artery anatomy); preservation of small vessels with which the affected area is associated; lack of foreign bodies. The disadvantages are: duration; narrow specialization: the only indication for surgery is the presence of atherosclerotic plaques.
Carotid endarterectomy is a routine surgical procedure that usually goes without serious consequences. The most dangerous of them is ischemic stroke. The risk of stroke is only 2%, and the risk of lethal outcome is 1%. Mild complications are more common, but they are less dangerous. These include: pain, numbness in the suture area; bleeding from the wound; infection of the suture; nerve damage; recurrent narrowing of the external or internal artery (restenosis).
It is one of the most common types of endovascular surgery. Operations on the carotid arteries by using this technique are recommended for patients who have contraindications to other procedures.
Angioplasty is also performed in case of need of emergency treatment, because it is the safest surgical procedure. It consists of several stages:
It is open carotid artery surgery that involves placing an additional vessel (a shunt) above, below the narrowed area. Synthetic or natural (a patch of the patient’s own vein/ artery) prostheses are used. The main indication is long-lasting stenosis. Sometimes, to create a “detour”, the surgeon connects the subclavian artery with the carotid artery. This procedure is called carotid-subclavian shunting.
Prosthetics of the carotid arteries is a very complex procedure that requires a high level of surgical skills. First, the doctor needs to carefully remove the affected area, and then stitch a new vessel instead. Usually, the patient’s vein or its synthetic analogue serves as prosthesis. This type of carotid artery surgery is performed very rarely because of the high level of trauma. The main indication is the inability to restore blood circulation through the use of other techniques.
To manage carotid artery aneurysms, open and endovascular techniques are used. Preference is given to the latter, especially when the affected area is difficult to approach.
Possible treatment options:
Pathological tortuosity or kinking refers to the elongation of arteries with the formation of various kinks, loops. Such changes in the structure of the vessel are often accompanied by blood flow disorders, the appearance of cholesterol plaques on the walls of blood vessels. With pronounced hemodynamic disorders, the only method of treatment is excision (resection) of the pathological area. After its removal, the remaining ends of the vessel are stitched together.
After carotid artery surgery, the patient spends several days in the hospital. Usually this period lasts 2-3 days. Patients with high blood pressure after surgery are placed in the intensive care unit. The stitches are removed on the 7-10th day. With a favourable postoperative course, you can return to work 1-2 weeks after surgery.
During recovery, it is recommended: