An endarterectomy is a surgery that removes plaque from the inside of a narrowed or blocked artery to restore normal blood flow. The plaque is a buildup of fatty, calcified material that accumulates on artery walls over time, and when it narrows an artery enough to restrict blood flow or threatens to break loose and cause a stroke, surgery becomes an option. The most common version of this procedure targets the carotid arteries in the neck, but endarterectomies can be performed on arteries throughout the body.
Where Endarterectomies Are Performed
The word “endarterectomy” simply refers to the surgical removal of material from inside an artery. Different types are named for the artery being treated:
- Carotid endarterectomy removes plaque from the arteries running through your neck to your brain. This is by far the most common type, performed to prevent stroke.
- Femoral endarterectomy clears plaque from arteries in the groin that supply blood to the legs, typically for peripheral artery disease.
- Coronary endarterectomy removes plaque from the arteries feeding the heart muscle.
- Aortic and iliac endarterectomy targets the main arteries in the abdomen and pelvis.
- Pulmonary endarterectomy removes chronic blood clots from the arteries leading to the lungs.
- Visceral endarterectomy clears blockages from arteries supplying the intestines and kidneys.
Because carotid endarterectomy is the most widely studied and frequently performed version, much of the research on outcomes, risks, and recovery centers on this procedure.
Who Qualifies for Surgery
Not every blocked artery needs surgery. For carotid artery disease, the decision hinges on two factors: how much the artery has narrowed and whether the narrowing has already caused symptoms like a mini-stroke (transient ischemic attack) or a full stroke.
Guidelines classify narrowing into three categories: mild (less than 50%), moderate (50% to 69%), and severe (70% to 99%). For people who have already experienced stroke symptoms, all major guidelines recommend medication alone for mild narrowing. At moderate narrowing, surgery becomes an option for certain patients. At severe narrowing, virtually all guidelines recommend endarterectomy as the standard treatment, provided no other health issues make surgery too risky.
For people without symptoms, the threshold for recommending surgery is higher because the immediate risk of stroke is lower. The procedure needs to carry very low complication rates to justify operating on someone who hasn’t had symptoms: less than 2% combined risk of stroke and death, compared with less than 6% for symptomatic patients.
Femoral endarterectomy follows a different set of criteria, but the principle is similar. It’s considered the gold standard for treating significant blockages in the common femoral artery, particularly for advanced peripheral artery disease. Patient selection matters here too, because this is not a minor procedure, especially for people with multiple other health conditions.
What Happens During the Procedure
A carotid endarterectomy is performed under general anesthesia. The surgeon makes an incision in the neck to expose the blocked carotid artery, then clamps the artery above and below the plaque to temporarily stop blood flow through that section. The artery is opened with a lengthwise cut, and the surgeon carefully peels the hardened plaque away from the artery wall.
While the artery is clamped, the brain’s blood supply through that artery is interrupted. Surgeons monitor brain activity continuously during the procedure, and if blood flow drops too low, they insert a small temporary tube called a shunt to reroute blood around the work area and keep the brain supplied. Not every patient needs a shunt; it depends on how well blood reaches the brain through other pathways.
Once the plaque is removed, the artery is closed with fine stitches. In some cases, the artery is too narrow or curved to simply stitch shut without risking a new blockage. When that happens, the surgeon sews in a small patch made of synthetic material to widen the artery at the closure site. The clamps are then released, restoring normal blood flow, and the incision in the neck is closed.
Risks and Complications
The central irony of carotid endarterectomy is that a surgery designed to prevent stroke carries a small risk of causing one. Plaque fragments can break free during the procedure, or a clot can form at the surgical site afterward. In large studies, the combined rate of any stroke or death within 120 days of surgery was about 4.2% for symptomatic patients. The 120-day all-cause mortality rate was 0.8%.
Other potential complications include nerve injury in the neck, which can temporarily affect swallowing or voice, and bleeding or infection at the incision site. Heart attack is another recognized risk, particularly in patients with existing heart disease.
Certain factors put patients at higher surgical risk. These include significant heart disease, severe lung disease, a previous endarterectomy on the same artery that has re-narrowed, prior radiation therapy or radical surgery on the neck, paralysis of the nerve controlling the vocal cord on the opposite side, complete blockage of the opposite carotid artery, and age over 80. When these factors are present, a less invasive alternative may be considered instead.
Endarterectomy vs. Stenting
The main alternative to carotid endarterectomy is carotid artery stenting, a less invasive procedure where a tiny mesh tube is threaded through a blood vessel (usually from the groin) and expanded inside the narrowed artery to hold it open. No neck incision is required.
A large meta-analysis pooling data from over 16,000 patients found that endarterectomy had significantly lower rates of stroke compared to stenting. The combined risk of stroke or death was also significantly lower with surgery. However, stenting had a meaningful advantage in one area: patients who received a stent experienced fewer heart attacks than those who had endarterectomy. When all major complications were combined (stroke, death, and heart attack together), the overall difference between the two procedures was not statistically significant.
This tradeoff means the best choice depends on the individual patient. Someone with serious heart disease may be better served by stenting to avoid the cardiac stress of open surgery. Someone at average cardiac risk but high stroke risk is generally better off with endarterectomy. Anatomical factors matter too: a very high blockage that’s hard to reach surgically, or a neck scarred by previous surgery or radiation, can make stenting the more practical option.
Long-Term Stroke Prevention
The long-term data on endarterectomy shows a durable benefit. In studies following patients for years after the procedure, the risk of stroke at five years was 6.9% in the surgery group compared with 10.9% in patients treated with medication alone. At ten years, the gap persisted: 13.4% versus 17.9%. These numbers reflect that endarterectomy doesn’t eliminate stroke risk entirely, but it meaningfully reduces it over a long period, particularly for patients who had significant narrowing to begin with.
It’s worth noting that medical therapy for artery disease has improved substantially since some of these landmark trials were conducted. Better blood pressure control, cholesterol-lowering medications, and antiplatelet drugs have narrowed the gap between surgical and non-surgical management for some patients, particularly those without symptoms.
Recovery After Surgery
Most people stay in the hospital overnight so the care team can monitor for complications, particularly signs of stroke or bleeding at the surgical site. The majority go home the following day. After discharge, you’ll typically start or continue taking blood-thinning medications like aspirin or similar drugs to prevent clots from forming at the surgical site.
Recovery at home generally involves keeping physical activity light for the first few weeks. The neck incision heals over a similar timeline to most surgical wounds. Follow-up imaging is usually scheduled to confirm that the artery remains open and blood is flowing normally. The incision site may feel numb or tight for a while as nerves in the area recover, but this typically improves over weeks to months.