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Surgery for Carotid Artery Disease

Most people who have plaque in a carotid artery can be treated with medications and lifestyle changes alone. However, those who have more severe blockages have a higher risk of stroke and should be evaluated to see if they may benefit from surgical treatment.

At NYU Langone, our doctors use a surgical procedure called carotid endarterectomy to treat most people who have severe carotid artery disease. For others, stenting with carotid angioplasty or transcarotid artery revascularization (TCAR) are the preferred treatment options.

Carotid Endarterectomy

At NYU Langone, most people with severe blockages in the carotid arteries are treated with carotid endarterectomy, also known as open surgery. This includes people who have blockages of 80 percent or more of the width of the artery, whether or not they have symptoms. People who have smaller blockages of 50 percent or more who have experienced a ministroke or stroke are also candidates for this procedure.

To perform carotid endarterectomy, your surgeon numbs the side of the neck with a local anesthetic. You are also given medication to help you relax. Carotid endarterectomy is performed with local anesthesia, so you are awake during the procedure. It is easier for the doctor to monitor blood flow to the brain when you are awake, which helps him or her determine whether a tube called a shunt is needed.

After the surgical site is completely numb, your doctor makes an incision near the carotid artery. Next, he or she uses clamps to temporarily close the carotid artery.  Sometimes a shunt is placed to ensure normal blood flow to the brain during this procedure.

The surgeon then makes an incision, removing plaque from the artery. He or she closes the incision using a synthetic or biological patch, which may be made from a vein in the body. This patch widens the carotid artery to help prevent it from narrowing again. The clamps are then removed, and normal blood flow to the brain is restored.

The surgery takes about two hours and typically requires an overnight stay in the hospital. You can typically resume normal activities within several weeks.

Carotid Angioplasty and Stenting

Carotid endarterectomy is not used in some people, because of the shape of the arteries or because of advanced age or other medical conditions. For these people, carotid angioplasty and stenting may be an alternative.

Carotid angioplasty and stenting works by moving the plaque against the walls of the carotid arteries. This widens the pathway, allows for better blood flow, and prevents plaque from dislodging and traveling to the brain.

During carotid angioplasty, also called balloon angioplasty, the doctor introduces a needle in the groin to access the femoral artery. Using X-ray guidance, he or she then advances a long hollow tube called a catheter to the blockage in a carotid artery in the neck. A filter is used to prevent any pieces of plaque from breaking off and traveling to the brain during the procedure.

A tiny balloon at the end of the catheter is inflated, pushing plaque to the sides of the artery walls. Next, the surgeon inserts a small metallic mesh tube called a stent into the artery, which opens it. This stent prevents the carotid artery from narrowing again.

The surgeon removes the balloon, the filter, and the catheter but leaves the stent in place permanently. The procedure, performed with general anesthesia, lasts 90 to 120 minutes and typically requires a one-night stay in the hospital. You can likely resume everyday activities within two days.

Transcarotid Artery Revascularization

For people who have a higher risk of complications from surgery, transcarotid artery revascularization (TCAR) might be a treatment option.

During this procedure, your surgeon makes a small incision just above the collarbone. He or she places a small tube into the carotid artery. The tube is connected to a surgical system that reverses the flow of blood through the carotid. The blood leaves the body and goes through a filter, which catches any small pieces of plaque. The blood is then returned to your body though the femoral vein in the groin.

While blood flow is reversed so it travels away from the brain, your doctor performs angioplasty to open the artery and places a stent to keep it open. After the surgery is completed, normal blood flow is restored.

Reversing the flow of blood and filtering it prevents plaque debris from traveling to the brain. This virtually eliminates the risk of stroke during the procedure. TCAR requires a smaller incision than open surgery and is less invasive, because the carotid is accessed from the collarbone instead of the groin.

TCAR is generally recommended for people who are considered high-risk for other surgical procedures due to existing cardiac disease or prior neck radiation or surgery.

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