Endarterectomy

What is an endarterectomy?

An endarterectomy (en-DAR-tuh-RECK-toh-mee) is a surgery to open narrowed or blocked arteries. Your healthcare provider uses the procedure to remove plaque, a fatty and calcified substance that can build up in arteries. Removing this buildup improves blood flow through your arteries and reduces your risk of blood clots or stroke.

Providers can use an endarterectomy to treat various forms of atherosclerosis. This is plaque buildup in an artery that eventually leads to stiff, narrowed arteries. Usually, providers use endarterectomies for moderate to severe cases, especially if you have symptoms.

Conditions an endarterectomy procedure treats include peripheral artery disease (PAD) and carotid artery disease.

In PAD, plaque builds up in the arteries in your legs or arms. This blocks blood flow and may lead to pain, wounds and eventual death (gangrene) of your tissues.

Carotid artery disease is plaque buildup in your carotid arteries. These are blood vessels that carry blood to your brain. Narrow carotid arteries can lead to a stroke, transient ischemic attack (TIA) or transient blindness if you don’t get treatment.

Types of endarterectomies

The type of endarterectomy procedure you have depends on where you have a blocked artery:

• Aortic and iliac endarterectomy removes plaque from the main arteries in your abdomen (belly) and pelvis.
• Carotid endarterectomy removes plaque from the arteries running through your neck to your brain. These procedures are common.
• Coronary endarterectomy takes plaque out of your coronary arteries, which bring blood to your heart.
• Femoral endarterectomy removes plaque from femoral arteries in your groin going to your legs.
• Pulmonary endarterectomy takes chronic blood clots out of your pulmonary arteries. These procedures are rare.
• Visceral endarterectomy removes plaque from the arteries to your intestines and kidneys. These procedures are rare.

How should I prepare for this procedure?

Before an endarterectomy procedure, you’ll likely have tests to evaluate the extent of the artery blockage, including:

• Doppler ultrasound, using sound waves to evaluate the location of blockages and the amount of blood flow through your blood vessels
• CT angiography, using advanced X-rays and contrast dye injected through an IV to make a three-dimensional picture of your body and blood vessels
• Angiography, using X-rays and a contrast dye injected directly into your arteries to take pictures of your blood vessels
• Magnetic resonance angiography (MRA), using magnets and radio waves to take pictures of your blood vessels

Your provider will give you instructions to prepare for an endarterectomy. You may need to stop taking certain medications, like blood thinners (anticoagulants), temporarily. In other cases, your provider may tell you to start taking antiplatelets, like aspirin, before surgery.

You’ll need to fast before an endarterectomy. Your anesthesia team will tell you how long to fast before the operation.

You may also have tests to assess your overall heart health, like an echocardiogram or stress test. Cardiovascular tests help your provider evaluate your heart attack risk and determine if you’re a good candidate for surgery.

Who isn’t a candidate for an endarterectomy?

Some people have risk factors that mean endarterectomy isn’t a suitable treatment option. You may not be a candidate for an endarterectomy if you have conditions that would make the surgery more dangerous, like:

• Decompensated congestive heart failure
• Recent heart attack
• Symptomatic coronary heart disease that’s not repairable
• Severe emphysema or COPD
• Radiation damage to the area
• Infection in the area
• Extensive calcification

But a provider may be able to remove blockages through a minimally invasive option called atherectomy. They may be able to treat others with metal scaffolds (stents) to open up the blockages.

How is an endarterectomy performed?

You receive anesthesia so you don’t feel any pain during an endarterectomy. Most people will be under general anesthesia and unconscious. But your provider may use regional anesthesia like a spinal block or keep you awake using local anesthesia. The most common procedure providers do with local anesthesia is a carotid endarterectomy to better monitor your brain function.

For a carotid endarterectomy, a provider may place a tube (shunt) to keep blood flowing to your brain during the procedure.

During an endarterectomy, your healthcare provider:

1. Makes an incision directly over the blocked artery
2. Removes plaque from the artery
3. Closes the artery with sutures, sometimes using a patch to widen the area to prevent re-narrowing (the patch can come from a synthetic graft or a piece of a healthy vein from another part of your body, if needed)
4. Closes the incision

How long does this procedure take?

A carotid endarterectomy takes about one or two hours. Times vary for other types of endarterectomies. Factors like the type of anesthesia you get and the medical conditions you have affect how long a procedure takes.

What are the potential benefits and risks of this procedure?

An endarterectomy procedure removes the blockages and restores your artery back to its normal, healthy size. The cleaned-out vessel can help heal leg wounds or resolve leg pain with walking or belly pain from poor circulation. It can also significantly reduce your risk of stroke.

The results of an endarterectomy usually last for many years.

Endarterectomies are typically safe, but there’s a risk of complications like:

• Bleeding
• Heart problems, like a heart attack
• Infection
• Nerve damage (often temporary)
• Re-narrowing in your artery
• Stroke

In most people, the risk of serious complications is low. It depends on the location and the reason for the surgery. If your provider recommends an endarterectomy, it means that they believe the benefits outweigh the potential risks.

Some factors can increase your risk of experiencing complications after an endarterectomy, including:

• Age, with risk increasing the older you are for most areas (for carotid blockages, some data shows endarterectomy to be safer than stenting the blockage)
• Conditions like untreated coronary artery disease and chest pain (angina), severe lung disease or decompensated congestive heart failure
• History of previous surgery or radiation to the area of your body where the operation will take place
• Plaque buildup in multiple arteries throughout your body

What happens after this procedure?

You may have a drainage tube extending from the incision site immediately after surgery to keep the area from bruising. Your provider will remove this before releasing you to go home. They’ll keep an eye on your vital signs as you recover.

You’ll likely be allowed to drink and eat a few hours after your procedure unless you have an incision in your abdomen. You may have some numbness or pain around the area where the provider cut into your skin.

Your provider may prescribe antiplatelets or anticoagulants for you. You may take these for several months after your surgery. If you have a pulmonary endarterectomy, you’ll take these blood thinners for the rest of your life.

How long does it take to recover from it?

The length of your hospital stay will depend on the type of surgery and location. You may need to stay in the hospital for:

• One day for a carotid endarterectomy
• Two to four days for a femoral endarterectomy
• One week for an aortic or visceral endarterectomy
• Ten days for a pulmonary endarterectomy

You’ll have a follow-up visit with your healthcare provider about four weeks after the endarterectomy. Your provider will examine the incision and image the repair over time with ultrasonography or CT scans. Most people can return to work after this follow-up visit. You may need at least six weeks to recover after an aortic, visceral or pulmonary endarterectomy.

Physical activity can help recovery, but it’s important to avoid strenuous activity until your provider tells you it’s OK. You may need to wait one or two months to return to work if you have a job that requires manual labor or strenuous physical activity. For aortic or visceral endarterectomy, you won’t be able to lift more than 10 pounds for two months until the abdominal area has healed and strengthened.

If you have stitches, a provider will need to remove them at a follow-up visit. If you had an endarterectomy in your leg, a provider may check your ankle-brachial index (ABI) every six months.

What is the life expectancy after endarterectomy?

This will depend on the area of your body that had the endarterectomy. The biggest risk is heart-related issues like heart attack down the road. But risk prediction methods don’t consider every factor. Everyone is different. Your healthcare provider is the best person to talk to you about your life expectancy.

When should I call my healthcare provider?

Call your provider right away if you have any signs of complication after an endarterectomy, including:

• Chest pain
• Difficulty breathing
• Fever or chills
• Numbness or weakness
• Swelling (edema), increased redness or discharge around the incision site
• Vision changes, slurring of speech or drooping of your face
• Nausea or vomiting

How is an endarterectomy different from a thrombectomy?

Both are procedures to improve blood flow in blood vessels. Healthcare providers can use an endarterectomy to remove plaque or (in rare cases) blood clots. A thrombectomy is only for removing blood clots.

Is endarterectomy the same as angioplasty?

No. In an endarterectomy, a provider surgically pulls plaque out of your artery. With angioplasty, a provider pushes plaque against the sides of your artery wall. Sometimes, they may destroy the plaque with a laser. Also, an angioplasty is a minimally invasive procedure.

Is an atherectomy the same as an endarterectomy?

No. Although both remove plaque, they do it differently. An atherectomy is a minimally invasive procedure. An endarterectomy is a surgical procedure that involves cutting directly into your artery.

In an atherectomy, a provider guides a catheter through your artery. When the catheter reaches the narrow or blocked section, a provider uses a tool at the end of the catheter to remove the plaque.

Is endarterectomy major surgery?

An endarterectomy is an open surgery, meaning it’s a major operation. You may stay in the hospital for one or several days, and recovery takes several weeks to months. But complications of a carotid or femoral endarterectomy are uncommon. People usually tolerate aortic and iliac endarterectomy well and have infrequent major complications.

Most people have long-lasting positive results from an endarterectomy.