Endarterectomy

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:

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  Carotid artery disease

  
  


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  Peripheral arterial disease, such as leg or arm artery disease

  
  


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  Renal (kidney) artery disease

  
  


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  Aortic arch conditions

  
  


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  Aortoiliac occlusive disease

  
  


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  Visceral (intestines, spleen, and liver) artery disease

  
  

How do I prepare?

To decrease your risk of developing blood clots, your physician may recommend that you take platelet-blocking medications, such as aspirin or clopidogrel (Plavix®) for several days before your procedure, depending on the location of the blockage in your artery. For some locations, however, he or she may ask you to temporarily stop taking these medications. Your physician will give you specific instructions since the use of these medications may vary depending upon your particular situation. In addition, some patients who require endarterectomy in a peripheral artery, such as a leg artery or the carotid artery, have a higher chance of having a heart attack because of associated blockages in the heart arteries (coronary artery disease). As a result, your physician may measure your heart health by performing a cardiovascular risk assessment, which may include a stress test. Also, to determine how much plaque is in your peripheral arteries and how well your blood is flowing through your arteries, your physician may recommend one or more of the following tests:

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  Duplex ultrasound, which uses high-frequency sound waves to measure real-time blood flow and detect blockages or other abnormalities in the structure of your arteries

  
  


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  Magnetic resonance angiography (MRA), which uses magnetic fields and radio waves to show blockages inside your arteries

  
  


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  Angiography, which produces x-ray pictures of the blood vessels in your legs using a contrast dye to highlight your arteries

  
  

Your physician or vascular surgeon will give you the necessary instructions you need to follow before the surgery, such as fasting. Usually, your physician will ask you not to eat or drink anything 8-12 hours before your procedure. Your physician will discuss with you whether to reduce or stop any medications that might increase your risk of bleeding or other complications.

Am I a candidate for endarterectomy?

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

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  Cancer

  
  


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  High blood pressure that has not been controlled by lifestyle changes or medications

  
  


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  Diabetes

  
  


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  Chest pain

  
  


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  A heart attack in the previous 6 months

  
  


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  Congestive heart failure

  
  


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

  
  

Am I at risk for complications during the procedure?

Your overall health may affect your risk for complications during the procedure. The type and risk of complications may vary with the location of the procedure. Considering carotid endarterectomy, for example, if you had a stroke in the past, your chances for complications may be increased compared to someone who has not had a stroke. Other factors that may increase your chances for complications with endarterectomy include:

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  Advanced age

  
  


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  The presence of another serious disease, such as cancer

  
  


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  Plaque blockage in other vessels

  
  


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  Having had a previous endarterectomy in the same location

  
  


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  High blood pressure that has not been controlled by lifestyle changes or medications

  
  


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  Diabetes

  
  


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  Congestive heart failure

  
  


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  Chest pain

  
  

Despite these potential problems, it may still be safer to have the endarterectomy despite the relatively increased risk. Your physician will discuss your particular situation with you.

What happens during endarterectomy?

The details of the procedure depend on the location of the artery to be treated.  Considering carotid endarterectomy, you will either be put to sleep or your vascular surgeon will numb the area over the artery and keep you awake so you can communicate during the surgery. By staying awake, you can help your surgeon monitor your brain's reaction to the decreased blood supply. If your anesthesiologist puts you to sleep, he or she will use machines to monitor your blood pressure, temperature, and brain function.

During the endarterectomy procedure, your surgeon makes an incision in the skin over the site of the blockage. Once the blockage in the artery is located, the surgeon may insert a tube, called a shunt, above and below the obstruction to temporarily reroute the blood flow. In some cases, your surgeon may only need to stop the blood with clamps for a short period instead of inserting the shunt. Your surgeon then uses a specially designed tool to remove the plaque or a blood clot from the inner layer of your artery. Once the plaque is removed and your artery is clean, your surgeon may widen the artery with a graft made of man-made material or a segment of one of your veins. Your surgeon then removes the shunt, if used, and the clamps, to restore the blood flow, and then closes the incisions.

Your surgeon may leave a thin, flexible tube, called a drain, in your incision temporarily to drain any excess fluid from the incision.

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:

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  Weakness

  
  


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  Numbness

  
  


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  Speech impairment

  
  


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  Vision problems

  
  


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  Chest pain

  
  


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  Fever, chills, wound drainage, or redness

  
  


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  Increasing swelling or pain

  
  


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  Difficulty breathing

  
  


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  Persisting vomiting

  
  

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

Are there any complications?

You may have complications following any surgical procedure and the type and risk of these depend upon the artery treated. A stroke is one possible complication following a carotid endarterectomy, for example. This risk is very low, ranging between 1 and 3 percent. Other complications of endarterectomy in general can include bleeding, re-blockage of the endarterectomy site, infection or heart problems. The risk of complications must be balanced against the risk of not having the endarterectomy if you need it. Your physician will help you choose the safest course for you.

What can I do to stay healthy?

Although a carotid endarterectomy may reduce your risk of stroke, it does not stop plaque from building up. To prevent hardening of the arteries from occurring again in the carotid or other locations, you should consider the following lifestyle changes:

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  Eat more foods low in saturated fat, cholesterol, and calories

  
  


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  Exercise regularly, especially aerobic exercises such as walking

  
  


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  Maintain your ideal body weight

  
  


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  Quit smoking

  
  


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  Monitor your blood cholesterol and fat levels under the direction of your physician who may advocate treatment with certain medications such as statins or anti-platelet agents