Awake carotid surgery means performing a carotid endarterectomy — removing the plaque that narrows the neck artery — under local or regional anaesthesia, with the patient conscious and able to speak and move. The reason is not comfort or novelty. It is that an awake patient is the most direct neurological monitor available during the one part of the operation where it matters. Performed by Prof. Dr. Yusuf Kalko in Istanbul, Turkey.

In short: during the operation the artery has to be clamped for a period. Most brains tolerate this through the other vessels that supply them; some do not, and need a temporary bypass tube (a shunt). Keeping the patient awake makes it possible to see within seconds who is in which group, so the shunt is used for the patients who need it rather than for everyone.

Why the operation is done at all

Plaque in the carotid artery threatens the brain mainly by shedding fragments that travel up and block a vessel, rather than by throttling flow. Removing that plaque in selected patients lowers the risk of a stroke. Whether an operation is indicated at all — and whether surgery or a stent is the better route — is a separate question, covered in carotid artery disease and in the article on carotid disease and stroke prevention.

The clamping problem

To open the artery and remove the plaque, the surgeon must stop the flow through it for a while. The brain is supplied by four arteries that connect to one another at its base, so in most people the other three compensate without difficulty. In a minority, that compensation is inadequate and the brain becomes short of blood during the clamp — which is exactly what the operation exists to prevent.

A shunt — a temporary tube carrying blood past the clamped segment — solves this. But inserting one is not free of risk in itself: it can dislodge plaque or injure the vessel wall, and it occupies the field the surgeon is working in. So the question is not whether shunts are good, but who actually needs one.

How that question is answered

Approach	How tolerance is judged	What it depends on
Awake (local or regional anaesthesia)	The patient is asked to speak and to squeeze a soft object in the opposite hand while the artery is clamped	Direct observation of the thing being protected — speech and limb function. Requires the patient to be able to cooperate
Asleep (general anaesthesia)	Indirect measures: back-pressure in the artery beyond the clamp, electrical brain activity, or blood-flow monitoring through the skull	Technology and interpretation; useful, but a step removed from the function itself

Both approaches are in routine use worldwide. The awake technique removes one layer of inference; general anaesthesia suits patients who cannot lie still or cooperate.

What the patient experiences, step by step

Before: the plan is explained, including exactly what you will be asked to do. Sedation can be given so that you are relaxed but still able to respond.
Anaesthesia: the side of the neck is numbed by injection around the nerves supplying it. You feel pressure and movement but not pain. A screen is placed so you do not see the operative field.
During: you are spoken to at intervals and asked to answer and to squeeze something with the hand on the opposite side. This continues particularly through the period when the artery is clamped.
If a problem appears: slurred speech or weakness in the hand shows up within seconds, and a shunt is placed immediately.
Afterwards: the artery is repaired and closed. A short period of close observation follows, with attention to blood pressure and neurological status.

Most people describe the experience as stranger than it is unpleasant: there is pressure and the sound of conversation, but no pain from the neck itself.

Who it suits — and who it does not

Suited	Less suited
Able to understand instructions and respond	Significant confusion, dementia or an inability to cooperate
Able to lie reasonably still and flat for the duration	Severe breathlessness lying flat, or a tremor or pain that prevents stillness
Prefers to avoid general anaesthesia, or has a heart or lung condition that makes it riskier	Marked anxiety that would make an awake procedure distressing — this is a legitimate reason to choose general anaesthesia
Anatomy suitable for an operation rather than a stent	A very high plaque or a hostile neck after previous surgery or radiotherapy, where a stent may be preferred
Can communicate with the team during the procedure	A language barrier — the technique depends on real-time communication, so interpretation arrangements must be settled in advance

The choice between awake and asleep is made with the patient, not imposed; both are legitimate.

That last row matters particularly for patients travelling from abroad. The whole point of the technique is live communication during the operation, so if English or Turkish is not shared comfortably with the team, interpretation must be arranged beforehand rather than improvised on the day.

Risks discussed before the decision

Any carotid procedure carries a small but real risk of causing the very event it is meant to prevent — this has to be stated plainly, because an operation performed to avoid a stroke can occasionally cause one. Also discussed: injury to the cranial nerves in the neck, which can affect the voice, swallowing or tongue movement and is often temporary; bleeding or a haematoma in the neck; cardiac strain; and the possibility of the narrowing recurring later. These risks are weighed against the stroke risk of leaving the plaque alone, which is why the indication is assessed before the technique is chosen.

Before or after surgery, these are emergencies: sudden weakness or numbness on one side, slurred speech, a drooping face, or temporary loss of vision in one eye — even if the symptoms resolve within minutes. After the operation, also seek help urgently for rapidly increasing neck swelling or difficulty breathing. Call the emergency services rather than waiting for an appointment.

After the operation

Short hospital stay with close neurological and blood-pressure monitoring,
Medicines continue — antiplatelet treatment and cholesterol-lowering therapy address atherosclerosis as a disease, while the operation addressed one location. Stopping them after a successful procedure is a common and avoidable mistake,
Numbness around the incision or a change in voice may appear and usually improves over weeks,
Follow-up Doppler at intervals, to check both the treated side and the other one,
The same risk factors threaten the heart and legs, so assessment usually extends beyond the neck — see vascular check-up.

Why Choose Turkey (Istanbul)?

Experienced vascular surgery with open, catheter-based and hybrid techniques in one centre,
Non-invasive assessment first — pulse examination, ankle–brachial index and Doppler before any decision,
English-language correspondence for international patients,
Pre-travel remote review of your reports, then an examination on arrival in Istanbul.

How to Start From Abroad (Remote Consultation)

Send your medical reports and imaging for an initial review before travelling. If you are asking about this technique specifically, mention which language you are comfortable being spoken to in during an operation — it affects whether the awake approach is suitable. The practical sequence — what to send, what can and cannot be decided remotely, and what determines the length of stay — is set out on the contact page.

Frequently Asked Questions

Will I feel the operation?

The neck is numbed with local or regional anaesthesia, so pain is not expected. You will be aware of pressure, movement and the team talking. Sedation can be given to keep you relaxed while still able to answer, and a screen prevents you from seeing the operative field.

Why not simply use a shunt for everyone?

Because placing a shunt is not risk-free: it can dislodge plaque or injure the vessel wall, and it takes up room in the area being operated on. The aim is to use it in the patients who genuinely need it, and being awake is the most direct way to identify them.

What happens if I cannot tolerate the clamping?

It becomes apparent within seconds — speech becomes unclear or the hand weakens — and a shunt is placed straight away to restore flow while the operation continues. This is precisely the situation the technique exists to detect.

Is awake surgery better than general anaesthesia?

Neither is superior for every patient. The awake technique removes a layer of inference by monitoring function directly; general anaesthesia suits patients who cannot lie still, cannot cooperate, or would find an awake procedure distressing. Both are in routine use, and the choice is made together.

I do not speak Turkish or English well. Does that matter?

Yes, and it should be settled before the day. The technique depends on real-time communication during the operation, so interpretation needs to be arranged in advance — or general anaesthesia with instrument-based monitoring chosen instead.

How long does it take?

The operation itself typically takes a little over an hour, with preparation and monitoring before and after. The clamping period, during which you will be asked to speak and squeeze, is a limited part of it.

Is surgery always the right choice over a stent?

No. The decision between medical treatment, surgery and stenting depends on whether the narrowing has caused symptoms, its degree, your anatomy and your general condition — set out in carotid artery disease.

References

This content is for information purposes only and does not replace a medical consultation. Diagnosis and treatment require an in-person examination.