The purpose of surgical treatment is to remove the atheromatous plaque with its debris and its clots. This is called a carotid endarterectomy. The length and the hospitalization procedures differ from one center to another as well as with each patient. We describe here the most frequent surgical admissions procedures for carotid stenosis in our unit of carotid surgery.
A- HOSPITALIZATION PROCEDURES
Except for emergencies, hospitalization is preceded by a consultation with the surgeon, followed by a consultation with the anesthesiologist to study the patient’s medical history, to organize the hospitalization, to prescribe or interrupt certain medical treatments and to answer all the patient’s questions. The patient is hospitalized the eve of the operation so that pre-operatory exams can be carried out and the patient can be visited by the specialists who will be caring for him. The surgery takes place on the following day. It lasts between 1 ½ hours to 3 hours. The patient leaves the hospital 2 to 4 days later.
B - THE OPERATION
Several different anesthetic and surgical techniques exist to operate on the carotid. We will describe one of the variants of carotid endarterectomy with a patch, under local anesthetic. Before the operation, a medication is injected into the patient to alleviate his anxiety and relax him. The patient is then placed as comfortably as possible on the operating table. Local-regional anesthesia consists of injecting the medication in contact with neck nerves which will eliminate any pain at this point. The anesthesiologist remains close to the patient, ready to administer any further medication required for eventual discomfort. Once the patient is relaxed and desensitized but remaining conscious and breathing normally, the intervention can then begin. Thus, it is easy to verify the degree of tolerance of the interruption of blood flow in the carotid clamping necessary to perform the endarterectomy. The operation begins with the control of the carotid bifurcation. The anesthesiologist injects in the drip an anti-coagulant to fluidify the blood. The surgeon interrupts the blood flow in the carotid with three clamps (a clamp is a metal instrument to pinch the artery to interrupt the blood to flow). A clamp is placed on the internal carotid, a clamp on the external carotid and a clamp on the common carotid artery. Under local anesthesia, the anesthesiologist asks patient who is conscious and relaxed to count to 60 and squeeze and open the hand for about a minute in order to confirm that the brain is receiving blood from the other carotid and the vertebral arteries during the intervention. If the patient does not squeeze well his hand, the surgeon puts in place a shunt (small tube which will feed the brain during the operation). Only then does the surgeon open the carotid and detach the atheroma plaque. When the plaque is removed along with the debris, then he closes with extreme care the artery with a highly resistant fine thread. If the artery is small, the surgeon will enlarge it with a patch (a small piece of fabric in Dacron). Once the artery is closed, the surgeon removes the clamps to re-establish the blood circulation in the carotid. He places a small drain in contact with the carotid. The tissues and the skin are then closed with reabsorb- able thread. The small drain is usually removed the day following the operation.
Numerous other techniques exist:
General anesthesia consists in putting the patient completely to sleep. The patient’s tolerance to the interruption of the blood flow is then evaluated with specific instruments. The eversion endarterectomy consists in sectioning transversely the carotid and proceeding with the operation by rolling back the walls. Bypass consists in joining up the carotid from one end to the other of the plaque of atheroma with a prosthetic tube or with a vein.
C - FOLLOW UP TO THE OPERATION
After the operation, the patient is conscious with a drip in place and a small cervical drain. He stays in the reanimation unit between two and three hours while the nurses monitor his blood pressure and the other vital signs. They administer analgesics if necessary. However, it should be noted that the scar is rarely painful. During this permanence an angiography is performed to check the operated carotid. The patient is subsequently transferred to the surgical Intensive Care Unit to check his neurological state as well as his blood pressure. The following morning after the surgeon’s visit the drip and small cervical drain are removed and the patient can eat breakfast, get up (under the surveillance of a nurse) and wash himself. He is then transferred to a hospitalization floor. Two to four days later the patient is released. He will continue his medical treatment which may be modified. He is advised to diminish his activities, remain calm for 15 days (walks are authorized). There are no foreseen local treatments. A complete shower including the scarred area (if the scar is clean and free of discharge) can be taken 3 days after release from the hospital. The scar should be protected from sunshine for several months. The patient may feel anesthetized in the jaw for as long as a year after the operation has taken place. Following the intervention the permeability of the operated carotid is checked with an echo-doppler after 6 months, then once a year. Regular doctor’s visits are indispensable for medical surveillance, and risk factors of artherosclerosis (cholesterol, glycemia, blood pressure, etc.). Regular physical activity is highly recommended.
D - COMPLICATIONS
Carotid surgery has been evaluated by studies comparing the frequency of the level of complications, notably stroke of operated and non-operated patients. These studies concluded that in the case of a tight stenosis of the carotid, the frequency of these complications was considerably lower among operated patients. Furthermore, according to these studies, carotid surgery has made several advances which diminish its risks even more. Certain complications, in particular cardio respiratory, can occur during any surgical intervention. Particular complications are more specific to carotid surgery: stroke, cervical hematoma, or injury to certain nerves which pass in proximity of the carotid and thereby modify the voice or create an obstacle to speech, chewing or swallowing. Most of these complications regress with appropriate treatment or further surgery.