Carotid artery surgery is a procedure to restore blood flow through a narrowed carotid artery, the major blood vessel on each side of your neck that supplies your brain. The most common version, called carotid endarterectomy, involves opening the artery and physically removing the fatty buildup (plaque) that’s blocking it. It’s one of the most effective ways to prevent a stroke in people with significant blockages, and surgeons in the U.S. perform tens of thousands of these procedures every year.
Why the Carotid Arteries Matter
Your two carotid arteries carry oxygen-rich blood from your heart up through your neck and into your brain. Over time, cholesterol and other fatty deposits can build up inside these arteries, a condition called carotid stenosis. As the artery narrows, less blood reaches the brain. Pieces of plaque can also break loose and travel to the brain, blocking smaller vessels and triggering a stroke or a transient ischemic attack (TIA), sometimes called a mini-stroke.
Many people with carotid stenosis have no symptoms at all until the blockage is severe. Others experience warning signs like sudden numbness on one side of the body, trouble speaking, or temporary vision loss in one eye. These episodes are what doctors call “symptomatic” stenosis, and they signal a much higher near-term stroke risk.
Who Needs Carotid Surgery
Whether surgery is recommended depends on two things: how much the artery is blocked and whether you’ve already had symptoms like a TIA or stroke.
For people who have experienced symptoms, current guidelines support surgery when the artery is more than 70% blocked. At that level, large clinical trials have shown a clear reduction in the five-year risk of disabling or fatal stroke. Surgery is also recommended for symptomatic blockages between 50% and 69%, though the benefit is smaller and the decision factors in other aspects of your health.
For people without symptoms, the threshold is generally 70% or greater, and guidelines add extra conditions: surgical risk must be very low (under 3% complication rate), life expectancy should be greater than five years, and imaging may need to show features that suggest the plaque is particularly unstable. The European Society for Vascular Surgery guidelines extend consideration to blockages as low as 60% in certain high-risk patients. Because asymptomatic stenosis carries a lower immediate stroke risk, the decision to operate is more nuanced and often involves close monitoring as an alternative.
Types of Carotid Artery Surgery
Carotid Endarterectomy
This is the traditional, gold-standard procedure. The surgeon makes an incision along the side of your neck, opens the carotid artery, and removes the plaque directly. Blood flow to the brain is temporarily rerouted or managed with a small shunt while the artery is open. The artery is then closed, sometimes with a patch to keep it wide, and blood flow is restored. Most surgeons use a microscope for the delicate work of separating plaque from the artery wall. The operation typically takes one to two hours.
Carotid Artery Stenting
Instead of opening the neck, this approach uses a thin catheter threaded through a blood vessel in the groin up to the blockage. A small balloon widens the narrowed section, and a metal mesh tube (stent) is placed inside to hold the artery open. There’s no neck incision, general anesthesia is often avoided, and hospital stays tend to be shorter.
However, stenting does not remove the plaque. It pushes it aside and holds it in place. That means there’s a risk of dislodging small fragments during the procedure. A Cochrane review of 10 trials involving over 5,000 symptomatic patients found that stenting carried a 70% higher risk of stroke or death around the time of the procedure compared to endarterectomy. Most of this extra risk came from minor, non-disabling strokes in patients older than 70. On the other hand, stenting had lower rates of heart attack, nerve injury in the neck, and bleeding at the procedure site. Once the periprocedural window passes, both procedures are equally effective at preventing future strokes.
Transcarotid Artery Revascularization (TCAR)
TCAR is a newer hybrid approach. The surgeon makes a small incision at the base of the neck to access the carotid artery directly, then places a stent while temporarily reversing blood flow away from the brain. This flow-reversal system acts as a safety net, catching any debris before it can reach the brain. Studies comparing TCAR to endarterectomy show similar 30-day rates of stroke, death, and heart attack (roughly 3% vs. 2.6%), and the stroke risk for TCAR alone is estimated at under 1% to 2%.
TCAR is typically reserved for patients who face higher risk with traditional open surgery. That includes people over 75, those with a history of head or neck radiation, prior neck surgery, or serious conditions like heart failure or severe lung disease.
Risks and Complications
The central risk of any carotid procedure is the thing it’s trying to prevent: stroke. During endarterectomy, stroke or death occurs in roughly 2% to 6% of cases depending on the patient population and study. The NASCET trial, one of the largest, reported a combined stroke and death rate of 5.8% in patients with severe blockages, though modern surgical techniques and patient selection have brought real-world numbers lower.
Nerve injury is another concern specific to endarterectomy. The surgery takes place in a tight space surrounded by nerves that control tongue movement, swallowing, voice, and parts of the face. In one surgical series, about 4% of patients experienced some form of nerve injury. The hypoglossal nerve, which controls the tongue, is the most commonly affected, followed by the marginal mandibular branch of the facial nerve. The reassuring finding is that nearly all of these injuries are temporary, resolving on their own over weeks to months. Data from the large European Carotid Surgery Trial puts the permanent nerve injury rate at just 0.5%.
Other possible complications include bleeding or bruising at the incision site, heart attack (roughly 1% risk), and a temporary spike in blood pressure that requires monitoring in the hours after surgery.
What Recovery Looks Like
After endarterectomy, you’ll stay overnight in the hospital so your care team can watch your blood pressure, neurological function, and the surgical site. Most people go home the next day. You can expect some neck soreness and stiffness, and the incision area may be swollen or tender for a few days.
Most people return to work and normal daily activities within one to two weeks. Driving is usually safe once the incision has healed and you can turn your head comfortably without pain. Heavy lifting and strenuous exercise are generally off-limits for a few weeks longer. Recovery from stenting or TCAR tends to be slightly faster because the incision is smaller or absent entirely.
Long-term, the repaired artery stays open in the vast majority of patients. You’ll likely have follow-up ultrasounds to check for re-narrowing, and managing the underlying causes of plaque buildup, including blood pressure, cholesterol, smoking, and blood sugar, remains essential to keeping the artery healthy and reducing the risk of problems on the opposite side.