Carotid artery disease occurs when fatty deposits (plaque) made of cholesterol, calcium, and other substances accumulate inside the carotid arteries. Over time, this build-up causes the arteries to harden and narrow, a condition called atherosclerosis.

When the narrowing becomes severe, blood flow to the brain is reduced, or a clot may form and travel to the brain, causing a stroke or a transient ischemic attack (TIA), often called a mini-stroke. The condition is more common in older adults, but risk factors such as smoking, high blood pressure, diabetes, high cholesterol, and a sedentary lifestyle can accelerate its development.

If a patient has experienced warning signs of stroke, such as sudden weakness or numbness in the face or limbs, difficulty speaking, vision changes, or loss of balance, and tests show more than 70 percent narrowing of the carotid artery, surgery is strongly recommended.

At this stage, the risk of a major stroke is high, and surgical intervention like carotid endarterectomy or stenting can significantly reduce that risk. In my experience, timely surgery in such patients can mean the difference between returning to normal life and facing permanent disability.

Some patients have no symptoms, but ultrasound or CT angiography reveals significant narrowing. If the blockage is more than 80 percent and the patient has additional risk factors like heart disease, uncontrolled diabetes, or a history of smoking, surgery may be advised to prevent future strokes.

This is especially true for younger patients with a long life expectancy, as their risk of developing symptoms or having a stroke increases over time. The decision is made after carefully weighing surgical benefits against possible risks.

The percentage of narrowing, known as the degree of stenosis, plays a central role in decision-making. Mild narrowing (less than 50 percent) is generally managed with medicines and lifestyle modifications. Moderate narrowing (50–69 percent) requires regular monitoring and may need surgery if symptoms appear. Severe narrowing (70 percent or more) almost always needs surgical correction in symptomatic patients, and often in selected asymptomatic patients too.

Before recommending surgery, I conduct a thorough evaluation of the patient’s heart, lungs, kidneys, and overall medical condition.

For example, a patient with uncontrolled heart disease may need cardiac optimization before carotid surgery. The surgical risk assessment ensures that the procedure is both safe and beneficial. It also helps determine whether the patient would be better suited for open surgery or a minimally invasive stenting approach.

Not every patient with carotid artery disease is an immediate candidate for surgery. In those with mild narrowing or high surgical risk, we focus on aggressive medical management – controlling blood pressure, lowering cholesterol, managing diabetes, prescribing antiplatelet medicines, and recommending regular physical activity. 

Quitting smoking is critical, as it can significantly slow disease progression. Such patients are closely monitored with regular Doppler ultrasounds to detect any changes that might require surgical intervention in the future.

Carotid Endarterectomy (CEA)

This is considered the gold standard for treating significant carotid artery narrowing. In this procedure, I make an incision in the neck to access the artery, open it, and carefully remove the plaque, along with a layer of the media of the artery, using specialised instruments. 

The artery is then repaired, usually with a patch, to restore smooth blood flow. CEA has been extensively studied and has proven to greatly reduce the risk of stroke in suitable patients.

Carotid Artery Stenting (CAS)

For patients who are not good candidates for open surgery due to anatomy or other medical conditions, carotid artery stenting offers a less invasive alternative. A small tube called a stent is placed inside the artery via a catheter inserted through the groin or wrist. While doing carotid angioplasty, most vascular surgeons would also use a filter device to prevent any small particles from moving to the brain during balloon dilation. 

The stent keeps the artery open, maintaining blood flow. While recovery is usually quicker, the choice between CEA and CAS depends on multiple factors, including plaque characteristics and patient health.

Choosing the right treatment requires a personalised approach. I consider the degree of narrowing, whether symptoms are present, patient age, overall health, and lifestyle. 

I also involve the patient and family in every step of the decision-making process so they clearly understand the benefits, risks, and expected recovery. Surgery is not the right choice for everyone, but for those who meet the criteria, it can be life-saving.