A carotid endarterectomy is a surgery to remove fatty plaque buildup from the carotid arteries, the two major blood vessels on either side of your neck that supply blood to your brain. The procedure is one of the most effective ways to prevent stroke in people with significant narrowing of these arteries. It has been performed for decades and remains the standard surgical treatment for carotid artery disease.
Why the Procedure Is Done
Your carotid arteries can gradually narrow as cholesterol and other fatty deposits (plaque) accumulate along the inner walls. This condition, called carotid stenosis, reduces blood flow to the brain and creates a risk that pieces of plaque will break off and travel to the brain, blocking smaller vessels and causing a stroke. A carotid endarterectomy physically removes that plaque, restoring normal blood flow and eliminating the source of dangerous debris.
The surgery is most clearly beneficial for people who have already experienced stroke symptoms, such as a mini-stroke (transient ischemic attack) or a full stroke, and who have significant narrowing. Current guidelines recommend the procedure for symptomatic patients with 70 to 99% stenosis, provided the surgical team’s complication rate is below 6%. For symptomatic patients with moderate narrowing of 50 to 69%, the decision depends on individual factors like age, sex, and other health conditions.
For people with no symptoms, the threshold is typically 60% or greater narrowing, but only if the patient is expected to live at least three to five more years and the surgical complication rate is below 3%. In patients under 75 with asymptomatic narrowing, the ACST-1 trial found that surgery reduced the 10-year stroke rate by roughly 46% compared to medical management alone. Stroke risk dropped from about 17% to 11% over a decade.
What Happens During Surgery
The operation typically takes one to two hours. Your surgeon makes an incision along the side of your neck to expose the carotid artery, then clamps the artery above and below the area of plaque buildup to temporarily stop blood flow through that segment. The artery is opened lengthwise, and the surgeon carefully peels out the hardened plaque from the inner lining of the vessel.
While the artery is clamped, the surgical team monitors your brain’s blood supply. If monitoring shows that your brain isn’t getting enough blood through the other carotid artery and connecting vessels, the surgeon inserts a small temporary tube called a shunt to reroute blood flow around the work area. Not every patient needs one.
Once the plaque is removed, the artery is closed. In some cases, the surgeon stitches the artery shut directly. In others, particularly when the artery is narrow or curved, a small fabric patch is sewn over the opening to widen the vessel and reduce the chance of it narrowing again. The incision in your neck is then closed.
Anesthesia Options
The surgery can be performed under general anesthesia, where you’re fully asleep, or under local anesthesia, where the neck area is numbed but you remain awake. Staying awake allows the surgeon to check your brain function in real time by asking you to speak, squeeze a hand, or perform simple tasks. A large Cochrane review found no clear difference in stroke, death, or complication rates between the two approaches. The choice generally comes down to the clinical situation and the preferences of both you and your surgeon.
Risks and Complications
The central concern with any carotid surgery is the small but real risk of stroke during or shortly after the procedure. In a large study of nearly 9,000 patients, the in-hospital stroke rate was about 1.0%, the heart attack rate was 0.7%, and the death rate was 0.2%. The combined rate for all three events was 1.7%. These numbers reflect outcomes at experienced surgical centers, and individual risk varies based on your overall health and the severity of your artery disease.
Because the surgery takes place in a crowded area of the neck near several important nerves, temporary nerve injury is a known complication. The most commonly affected nerves control the tongue, vocal cords, and lower face. You might experience hoarseness, difficulty swallowing, tongue deviation to one side, or a slight droop at the corner of your mouth. In the CREST trial, these injuries affected quality of life mainly in the first two to four weeks, particularly with eating and swallowing, but did not persist at one year.
Endarterectomy vs. Stenting
The main alternative to endarterectomy is carotid artery stenting, a less invasive procedure where a wire mesh tube is threaded through a blood vessel (usually from the groin) and placed inside the narrowed carotid artery to hold it open. Stenting avoids a neck incision entirely, but the tradeoffs are different.
The landmark CREST trial, published in the New England Journal of Medicine, followed over 2,500 patients for a median of 2.5 years. Four-year stroke or death rates were 6.4% with stenting versus 4.7% with endarterectomy. During the procedure itself, stenting carried a higher risk of stroke (4.1% vs. 2.3%), while endarterectomy carried a higher risk of heart attack (2.3% vs. 1.1%). Over the long term, outcomes were similar when stroke, heart attack, and death were combined into a single measure.
In general, endarterectomy remains the preferred option for most patients who are good surgical candidates. Stenting is typically offered to patients whose anatomy or medical conditions make open neck surgery higher risk, such as those with prior neck radiation, a very high carotid blockage that’s difficult to reach surgically, or serious heart or lung disease.
Recovery Timeline
Most people stay in the hospital for one to two days after surgery. During that time, your blood pressure, heart rate, and neurological function are closely monitored. The neck incision is relatively small, and pain is usually manageable with standard medication.
After discharge, you’ll be told not to drive for a period of time while your neck heals and your comfort improves. Heavy lifting and strenuous activity are restricted in the early weeks. Most people return to their normal activities within three to four weeks. You’ll likely have a follow-up ultrasound to check blood flow through the treated artery, and long-term management includes controlling blood pressure, cholesterol, and other risk factors that contribute to plaque buildup in the first place.
Long-Term Effectiveness
The procedure has strong evidence behind it. In the ACST-1 trial, which tracked asymptomatic patients for a full decade, those who had surgery promptly experienced a stroke rate of about 10.8% over 10 years, compared to 16.9% in those who initially received only medical treatment. That roughly six-percentage-point difference held steady from five years out to ten years, meaning the benefit of surgery didn’t fade over time. The greatest benefit was seen in patients under 75 at the time of surgery.
For symptomatic patients, the evidence is even more compelling. Decades of trial data consistently show that removing severe plaque from the carotid artery dramatically lowers the chance of a repeat stroke or mini-stroke, particularly in the first few years after the event that prompted surgery. Combined with modern medications for blood pressure and cholesterol, the procedure gives patients a substantially lower lifetime stroke risk than medication alone can achieve in cases of significant narrowing.