Carotid endarterectomy

Carotid endarterectomy is a surgical procedure used to correct carotid stenosis (obstruction of the carotid artery by atheroma), used particularly when this causes medical problems, such as transient ischemic attacks (TIAs) or cerebrovascular accidents (CVAs, strokes). Endarterectomy is the removal of material on the inside (end-) of an artery. Angioplasty and stenting of the carotid artery is emerging as an alternative to carotid endarterectomy.

Procedure

Many surgeons lay a temporary shunt to ensure blood supply to the brain during the procedure. Some recommend neuromonitoring with electroencephalography (EEG) throughout the procedure.

The internal, common and external carotid arteries are clamped, the lumen of the internal carotid artery is opened, and the atheromatous plaque substance removed. The artery is closed, hemostasis achieved, and the overlying layers closed.

Indications

Carotid stenosis is diagnosed with ultrasound doppler studies of the neck arteries or magnetic resonance arteriography (MRA). Stenosis of >70% of the carotid lumen is generally deemed significant.

Generally, carotid stenosis is not corrected surgically unless it is symptomatic (by causing TIAs or strokes). Endarterectomy itself carries risks (embolisation into the brain with resultant stroke), which outweigh the benefits unless it actually causes symptoms. The circle of Willis typically provides a collateral blood supply. Symptoms have to affect the other side of the body; if they do not, they may not be caused by the stenosis, and repairing it will be of minimal benefit.

Contra-indications

The procedure cannot be performed in case of:

Complete internal carotid artery obstruction (because the intraluminal thrombus then extends too far downstream, well into the intracranial portion of the artery, for endarterectomy to be successful).
Previous stroke on the homolateral side with heavy sequelae because there is no point in preventing what has already happened.
Patient deemed unfit for the operation by the anaesthisiologist.

Complications

About 3% of patients will suffer neurological complications as a result of the procedure. Hemorrhage of the wound bed is potentially life-threatening, as swelling of the neck due to hematoma could compress the trachea. Neuropraxy of the hypoglossal nerve occurs rarely.

Reference

Biller J, Feinberg WM, Castaldo JE, Whittemore AD, Harbaugh RE, Dempsey RJ, Caplan LR, Kresowik TF, Matchar DB, Toole JF, Easton JD, Adams HP Jr, Brass LM, Hobson RW 2nd, Brott TG, Sternau L. Guidelines for carotid endarterectomy: a statement for healthcare professionals from a Special Writing Group of the Stroke Council, American Heart Association. Circulation 1998;97:501-9. PMID 9490248.

External link

Carotid endarterectomy (Baylor College of Medicine)