Carotid Endarterectomy
Imad Mokalled PGY2
Vascular Conference
Jan 10, 2017
Case Presentation
• BAA, 79 year old female patient presenting with left sided numbness
of the face, hand, and foot of 2 weeks duration.
• Lasting several minutes and resolving spontaneously.
• No weakness, gait change.
• No speech difficulty
• PMHx: HTN DM
• PSHx: thyroidectomy
• Meds: tritace, amaryl, galvus met, vastarel, tulip, euthyrox, aspicot
Case Presentation
Physical Exam:
• GA: NAD alert oriented*3
• Right Carotid bruit
• Radial Pulses: 2+ bilaterally
• Normal motor power and sensation in 4 extremities
• Normal gait
• Normal speech
• Cranial Nerves: 3-12 grossly normal
Case Presentation
• MRA brain: severe right internal carotid artery origin stenosis and
calcification
• Echo (4/1/2017): EF= 65-69% with mild aortic stenosis
Case Presentation
Carotid Duplex (3/1)
Case Presentation
• Venous Duplex (3/1)
Case Presentation
• OR (4/1)
Right carotid endarterectomy with harvesting of right greater saphenous
vein and insertion of 15F drain
Postop course: fine patient started on aspirin postop
Following day (5/1): drain removed foley removed
BP on high side nitroderm patch applied
Plavix started
Neuro exam normal
Discharged (6/1) on aspirin and plavix
Definitions and Indications
• Definition: CEA is the removal of the diseased intima and media of the
carotid artery.
• Aim: to prevent the adverse sequelae secondary to atherosclerotic
disease i.e ischemic stroke.
• Definition of symptomatic vs non-symptomatic:
• Sxic: either TIAs or minor stroke defined as a focal neurologic defect affecting
one side of the body, speech, or vision.
• Asxic: pts have narrowing but have not experienced a TIA or a stroke.
Definitions and indications (Cont’d):
• NASCET trial (1999): The North American Symptomatic Carotid Endarterectomy
Trial
• Prior studies had demonstrated the benefit of carotid endarterectomy (CEA) in
patients with severe carotid stenosis, but NASCET was the first large, well-
designed trial to study CEA in patients with low-moderate (<50%), high-moderate
(50-69%), and severe (≥70%) stenosis. Those with symptomatic 50-69% stenosis
had a 29% reduction in the 5-year risk of death or stroke, while those with <50%
stenosis had no such benefit. Those with ≥70% stenosis received such a dramatic
benefit that this study arm was prematurely stopped and all patients with severe
stenosis were subsequently referred for CEA.
• Bottom line: CEA reduces the 5-year risk of death or stroke by 29% among
patients with symptomatic high-moderate (50-69%) carotid stenosis.
Definitions and indications (Cont’d):
• ECST trial (1998): European Carotid Surgery Trial
• CEA significantly reduced the rate of major stroke or death compared
to usual medical care (14.9% vs. 26.5%; NNT=9) for >80% stenosis
• CEA did not appear to benefit patients with <80% stenosis.
Definitions and indications (Cont’d):
AHA/ASA Guidelines for Symptomatic CEA (2014, adapted)
•For patients with a TIA or ischemic stroke within the past 6 months and ipsilateral severe (70-99%)
carotid artery stenosis as documented by noninvasive imaging, CEA is recommended if the perioperative
morbidity and mortality risk is estimated to be <6% (Class 1A)
•For patients with recent TIA or stroke and ipsilateral moderate (50-69%) carotid stenosis as documented
by catheter-based imaging or noninvasive imaging with corroboration (MRA or CTA), CEA is
recommended
depending on patient-specific factors such as age, sex, and comorbidities if perioperative morbidity and
mortality risk is estimated to be <6% (Class 1B)
•When the degree of stenosis is <50%, CEA and CAS are not recommended (Class IIIA)
Definitions and indications (Cont’d):
• ACAS (1995): Asymptomatic Carotid Atherosclerosis Study
• 1st study examining carotid endarterectomy in asymptomatic patients
with carotid narrowing 60-99%
• Showed that over 5 years the risk of stroke or stroke and death was
reduced from 11% to 5.1%.
• There was no evidence of any more or less benefit as the narrowing
approached 99%.
Definitions and indications (Cont’d):
• ACST: Asymptomatic Carotid Surgery Trial
• Comparing patients without symptoms allocated immediate carotid
endarterectomy (for 60-99% stenosis) versus all those allocated non-
surgical management the net 5 year risk was 6.4% (with surgery)
versus 11.8% (only medical treatment).
• In men under the age of 75 years the benefit of surgery was clear cut
(8.2% decrease in 5 year risk of stroke with surgery).
• Follow up studies indicate there is a clear benefit for women which
appears close to or equivalent to the benefits for men.
Definitions and indications (Cont’d):
• Patients with asymptomatic carotid atherosclerosis should receive
intensive medical therapy: statin therapy, antiplatelet therapy, blood
pressure control, and lifestyle modification consisting of smoking
cessation, limited alcohol consumption, weight control, regular aerobic
physical activity, and a Mediterranean diet
• For medically stable patients who have a life expectancy of at least five
years and a high grade (≥80 percent) asymptomatic carotid stenosis at
baseline or have progression to ≥80 percent stenosis despite intensive
medical therapy while under observation, carotid endarterectomy (CEA)
is recommended, provided the combined perioperative risk of stroke
and death is less than 3 percent for the surgeon and center (grade 2b)
Definitions and indications (Cont’d):
• Repair the tightest side first
• Repair the dominant side first if the patient has equally tight carotid
stenosis bilaterally
• Use a shunt during CEA for stump pressures < 50 or if contralateral side is
tight, some always use a shunt.
• For maximum benefit patients should be operated on soon after a TIA or
stroke, preferably within the first 2 weeks as recommended by the
National Institute of Health and Clinical Excellence (NICE) guidelines.
Definitions and indications (Cont’d):
• The Carotid Revascularization Endarterectomy versus Stenting Trial
(CREST) funded by the National Institute of Health (NIH) reported that
the results of stents and endarterectomy were comparable.
• However, the European International Carotid Stenting Study (ICSS)
found that stents had almost double the rate of complications
Definitions and indications (Cont’d):
• Endarterectomy remains the preferred method of revascularization
for most patients with symptomatic carotid atherosclerosis who have
standard surgical risk. Nevertheless, accumulating evidence suggest
that CAS and CEA provide similar long-term outcomes for patients
with asymptomatic and symptomatic carotid occlusive disease, while
the periprocedural risk of stroke and death may be higher with CAS.
High risk criteria for CEA include the following:
• Age ≥80 years.
• Class III/IV congestive heart failure.
• Class III/IV angina pectoris.
• Left main or multi vessel coronary artery disease.
• Need for open heart surgery within 30 days.
• Left ventricular ejection fraction of ≤30%.
• Recent (≤30-day) heart attack.
• Severe lung disease or COPD.
• Severe renal disease.
• High cervical (C2) or intrathoracic lesion.
• Prior radical neck surgery or radiation therapy.
• Contralateral carotid artery occlusion.
• Prior ipsilateral CEA.
• Contralateral laryngeal nerve injury.
• Tracheostomy.
Surgical Details:
The incision is made along the anterior border of
the sternocleidomastoid muscle.
The platysma is incised
Facial Nerve (2.2%) marginal mandibular nerve
drooping at corner of the mouth, drooling
GAN: (C2-C3), sensory innervation for the skin
over parotid gland and mastoid process, and
both surfaces of the outer ear.
As the hypoglossal nerve is encountered it must be
identified and preserved. Risk of injury: 3.7%
tongue deviation to the side of injury.
Common carotid artery, vagus nerve and internal
jugular vein have common sheath, which has to be
opened prior to artery dissection. The IJV is lateral
to the artery, and Vagus nerve in between and
posteriorly to both.
Injury to the vagus nerve (2.5%) Vocal cord
paralysis usually results in hoarseness, impaired
phonation, and an ineffective cough
Tissue in this area should be manipulated as little
as possible to prevent separation of the
atherosclerotic plague inside the vessel.
The dissection of the external carotid artery and
its first branch the superior thyroid artery are
performed next, subsequently the other
branches of the ECA, the lingual, the external
maxillary or the facial… are dissected as well.
The dissection of the internal carotid artery is
completed last.
Special attention must be paid to another nerve
positioned in this area, the carotid body (or
sinus), which regulates arterial blood pressure.
• Other Nerves
• superior laryngeal nerve: voice
fatigue or alteration in sound
quality
• spinal accessory nerve: shoulder
drop
• glossopharyngeal nerve:
impairment of swallowing and
recurrent aspiration
• sympathetic chain: Horner’s
syndrome
The vascular clamps are applied to the common
carotid artery and internal carotid artery.
The ECA and superior thyroid artery are
controlled by gentle traction on the vessel loops.
A longitudinal incision is then made through the
adventitia on the anterolateral surface of the
carotid artery. The length of this incision is
extended inferiorly into the common carotid
artery below any obvious localized plaque.
• Temporary bypass shunt is inserted.
• Shunt first must be inserted into the
internal carotid artery to ensure
backflow.
• It is very important to have air and
debris cleared by the backflow of the
blood from the internal carotid artery
before gently inserting the shunt into
common carotid artery
• The shunt bypass is now in place,
providing circulation to the internal
carotid artery and to the cerebral
circulation
• Using a small blunt dissector, the plaque is mobilized
from the adventitia.
• The vessel wall is then
carefully inspected, and any
loose strips of atheroma that
remain are carefully peeled
away.
• The internal carotid artery is
closely inspected to ensure
that there is no loose flap
superiorly.
Complications:
• Perioperative or immediate complications
• central neurologic
• local (neck)
• cranial nerve injury
• hemorrhage
• Systemic
• alteration in blood pressure control
• myocardial infarction (MI)
• Late (after 30-day) complications
• recurrent carotid stenosis
• Suture line or patch disruption associated with infection
Complications (Cont’d):
Central Neurologic Complications or Death
• Perioperative Stroke or Death
• endarterectomy site thrombosis and/or embolism from the
endarterectomy site
• ischemia at the time of carotid clamping
• embolism during dissection
• embolism from remote sites
• Hyperperfusion/Cerebral Hemorrhage
• disturbed cerebral autoregulation that develops in the territory of a
carotid stenosis.
• unilateral headache, seizure activity, and cerebral hemorrhage
• 2 to 7 days
• Hyperperfusion: 2% to 3%
• Cerebral haemorrhage: 0.2% to 0.8%
Hyperperfusion/Cerebral
Hemorrhage
• Risk factors:
• very high-grade carotid stenoses
• contralateral occlusion
• Uncontrolled hypertension
• Diagnosis:
• MRI/MRA
• CT
• Treatment:
• seizure precautions and aggressive blood pressure management
• seizure medication prophylaxis
• Stop antiplat.
Thank you
