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Carotid Endarterectomy

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Carotid Artery Disease

Abstract

Carotid occlusive disease is a major cause of stroke or transient ischemic attack (TIA). Stroke is the second most common cause of mortality and third most common cause of disability worldwide (Lozano et al. Lancet 380:2095–2128, 2012). Carotid endarterectomy is perhaps the most extensively studied intervention for treatment of carotid stenosis, with many randomized controlled trials (RCTs) having established its efficacy in stroke prevention. This chapter discusses the indications, preoperative care, step-by-step surgical technique, postoperative management, as well as complications one should be aware of when performing CEA in the treatment of carotid artery disease.

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References

  1. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2095–128.

    Article  PubMed  Google Scholar 

  2. North American Symptomatic Carotid Endarterectomy Trial Collaborators, Barnett HJM, Taylor DW, Haynes RB, Sackett DL, Peerless SJ, et al. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med. 1991;325(7):445–53.

    Article  Google Scholar 

  3. Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. 1998;339(20):1415–25.

    Article  CAS  PubMed  Google Scholar 

  4. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet. 1998;351(9113):1379–87.

    Google Scholar 

  5. Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, et al. ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. J Am Coll Cardiol. 2011;57(8):1002–44.

    Article  PubMed  Google Scholar 

  6. Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA. 1995;273(18):1421–8.

    Article  Google Scholar 

  7. Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet. 2004;363(9420):1491–502.

    Article  CAS  PubMed  Google Scholar 

  8. Goessens BM, Visseren FL, Kappelle LJ, Algra A, van der Graaf Y. Asymptomatic carotid artery stenosis and the risk of new vascular events in patients with manifest arterial disease: the SMART study. Stroke. 2007;38(5):1470–5.

    Article  PubMed  Google Scholar 

  9. Marquardt L, Geraghty OC, Mehta Z, Rothwell PM. Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on best medical treatment: a prospective, population-based study. Stroke. 2010;41(1):e11–7.

    PubMed  Google Scholar 

  10. Jones DW, Goodney PP, Conrad MF, Nolan BW, Rzucidlo EM, Powell RJ, et al. Dual antiplatelet therapy reduces stroke but increases bleeding at the time of carotid endarterectomy. J Vasc Surg. 2016;63(5):1262–1270.e3.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Eliasziw M, Streifler JY, Fox AJ, Hachinski VC, Ferguson GG, Barnett HJ. Significance of plaque ulceration in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial. Stroke. 1994;25(2):304–8.

    Article  CAS  PubMed  Google Scholar 

  12. Kennedy J, Quan H, Buchan AM, Ghali WA, Feasby TE. Statins are associated with better outcomes after carotid endarterectomy in symptomatic patients. Stroke. 2005;36(10):2072–6.

    Article  CAS  PubMed  Google Scholar 

  13. Anderson KM, Odell PM, Wilson PW, Kannel WB. Cardiovascular disease risk profiles. Am Heart J. 1991;121(1 Pt 2):293–8.

    Article  CAS  PubMed  Google Scholar 

  14. GALA Trial Collaborative Group, Lewis SC, Warlow CP, Bodenham AR, Colam B, Rothwell PM, et al. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet. 2008;372(9656):2132–42.

    Article  Google Scholar 

  15. Theisen GJ, Grundy BL. Anesthesia and monitoring for carotid endarterectomy. Bull N Y Acad Med. 1987;63(8):803–19.

    CAS  PubMed  PubMed Central  Google Scholar 

  16. Blume WT, Ferguson GG, McNeill DK. Significance of EEG changes at carotid endarterectomy. Stroke. 1986;17(5):891–7.

    Article  CAS  PubMed  Google Scholar 

  17. AbuRahma AF, Hopkins ES, Robinson PA, Deel JT, Agarwal S. Prospective randomized trial of carotid endarterectomy with polytetrafluoroethylene versus collagen-impregnated dacron (Hemashield) patching: late follow-up. Ann Surg. 2003;237(6):885–92; discussion 892-3.

    PubMed  PubMed Central  Google Scholar 

  18. Rerkasem K, Rothwell PM. Patch angioplasty versus primary closure for carotid endarterectomy. Cochrane Database Syst Rev. 2009;(4):CD000160. https://doi.org/10.1002/14651858.CD000160.pub3.

  19. Bond R, Rerkasem K, Naylor R, Rothwell PM. Patches of different types for carotid patch angioplasty. Cochrane Database Syst Rev. 2004;(2):CD000071. https://doi.org/10.1002/14651858.CD000071.pub2.

  20. Dellagrammaticas D, Lewis SC, Gough MJ. GALA Trial Collaborators. Is heparin reversal with protamine after carotid endarterectomy dangerous? Eur J Vasc Endovasc Surg. 2008;36(1):41–4.

    Article  CAS  PubMed  Google Scholar 

  21. Ullery BW, Nathan DP, Shang EK, Wang GJ, Jackson BM, Murphy EH, et al. Incidence, predictors, and outcomes of hemodynamic instability following carotid angioplasty and stenting. J Vasc Surg. 2013;58(4):917–25.

    Article  PubMed  Google Scholar 

  22. O'Brien MS, Ricotta JJ. Postoperative treatment of patients undergoing carotid endarterectomy. J Vasc Nurs. 1994;12(1):1–5.

    CAS  PubMed  Google Scholar 

  23. Biller J, Feinberg WM, Castaldo JE, Whittemore AD, Harbaugh RE, Dempsey RJ, et al. Guidelines for carotid endarterectomy: a statement for healthcare professionals from a special writing Group of the Stroke Council, American Heart Association. Circulation. 1998;97(5):501–9.

    Article  CAS  PubMed  Google Scholar 

  24. Siddiqui A, Vora N, Edgell RC, Callison RC, Kitchener J, Alshekhlee A. Rupture of a cerebral aneurysm following carotid endarterectomy. J Neurointerv Surg. 2012;4(5):e27-2011-010091. Epub 2011 Sep 28.

    Article  Google Scholar 

  25. Rockman CB, Jacobowitz GR, Lamparello PJ, Adelman MA, Woo D, Schanzer A, et al. Immediate reexploration for the perioperative neurologic event after carotid endarterectomy: is it worthwhile? J Vasc Surg. 2000;32(6):1062–70.

    Article  CAS  PubMed  Google Scholar 

  26. Doig D, Turner EL, Dobson J, Featherstone RL, de Borst GJ, Brown MM, et al. Incidence, impact, and predictors of cranial nerve palsy and haematoma following carotid endarterectomy in the international carotid stenting study. Eur J Vasc Endovasc Surg. 2014;48(5):498–504.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Self DD, Bryson GL, Sullivan PJ. Risk factors for post-carotid endarterectomy hematoma formation. Can J Anaesth. 1999;46(7):635–40.

    Article  CAS  PubMed  Google Scholar 

  28. Shakespeare WA, Lanier WL, Perkins WJ, Pasternak JJ. Airway management in patients who develop neck hematomas after carotid endarterectomy. Anesth Analg. 2010;110(2):588–93.

    Article  PubMed  Google Scholar 

  29. Ijas P, Aro E, Eriksson H, Vikatmaa P, Soinne L, Venermo M. Prior intravenous stroke thrombolysis does not increase complications of carotid endarterectomy. Stroke. 2018;49:1843.

    Article  PubMed  Google Scholar 

  30. Rosenbaum A, Rizvi AZ, Alden PB, Tretinyak AS, Graber JN, Goldman JA, et al. Outcomes related to antiplatelet or anticoagulation use in patients undergoing carotid endarterectomy. Ann Vasc Surg. 2011;25(1):25–31.

    Article  PubMed  Google Scholar 

  31. Hye RJ, Mackey A, Hill MD, Voeks JH, Cohen DJ, Wang K, et al. Incidence, outcomes, and effect on quality of life of cranial nerve injury in the carotid revascularization endarterectomy versus stenting trial. J Vasc Surg. 2015;61(5):1208–14.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Schauber MD, Fontenelle LJ, Solomon JW, Hanson TL. Cranial/cervical nerve dysfunction after carotid endarterectomy. J Vasc Surg. 1997;25(3):481–7.

    Article  CAS  PubMed  Google Scholar 

  33. Massey EW, Heyman A, Utley C, Haynes C, Fuchs J. Cranial nerve paralysis following carotid endarterectomy. Stroke. 1984;15(1):157–9.

    Article  CAS  PubMed  Google Scholar 

  34. Matsumoto GH, Cossman D, Callow AD. Hazards and safeguards during carotid endarterectomy. Technical considerations. Am J Surg. 1977;133(4):458–62.

    Article  CAS  PubMed  Google Scholar 

  35. Bekelis K, Moses Z, Missios S, Desai A, Labropoulos N. Indications for treatment of recurrent carotid stenosis. Br J Surg. 2013;100(4):440–7.

    Article  CAS  PubMed  Google Scholar 

  36. Painter TA. Myointimal hyperplasia: pathogenesis and implications. 1. In vitro characteristics. Artif Organs. 1991;15(1):42–55.

    Article  CAS  PubMed  Google Scholar 

  37. Texakalidis P, Giannopoulos S, Jonnalagadda AK, Kokkinidis DG, Machinis T, Reavey-Cantwell J, et al. Carotid artery endarterectomy versus carotid artery stenting for restenosis after carotid artery endarterectomy: a systematic review and meta-analysis. World Neurosurg. 2018;115:421–429.e1.

    Article  PubMed  Google Scholar 

  38. Duschek N, Ghai S, Sejkic F, Falkensammer J, Skrinjar E, Huber K, et al. Homocysteine improves risk stratification in patients undergoing endarterectomy for asymptomatic internal carotid artery stenosis. Stroke. 2013;44(8):2311–4.

    Article  CAS  PubMed  Google Scholar 

  39. Ladowski JS, Shinabery LM, Peterson D, Peterson AC, Deschner WP. Factors contributing to recurrent carotid disease following carotid endarterectomy. Am J Surg. 1997;174(2):118–20.

    Article  CAS  PubMed  Google Scholar 

  40. Williams WT, Assi R, Hall MR, Protack CD, Lu DY, Wong DJ, et al. Metabolic syndrome predicts restenosis after carotid endarterectomy. J Am Coll Surg. 2014;219(4):771–7.

    Article  PubMed  Google Scholar 

  41. Sadideen H, Taylor PR, Padayachee TS. Restenosis after carotid endarterectomy. Int J Clin Pract. 2006;60(12):1625–30.

    Article  CAS  PubMed  Google Scholar 

  42. Garzon-Muvdi T, Yang W, Rong X, Caplan JM, Ye X, Colby GP, et al. Restenosis after carotid endarterectomy: insight into risk factors and modification of postoperative management. World Neurosurg. 2016;89:159–67.

    Article  PubMed  Google Scholar 

  43. LaMuraglia GM, Stoner MC, Brewster DC, Watkins MT, Juhola KL, Kwolek C, et al. Determinants of carotid endarterectomy anatomic durability: effects of serum lipids and lipid-lowering drugs. J Vasc Surg. 2005;41(5):762–8.

    Article  PubMed  Google Scholar 

  44. O'Hara PJ, Hertzer NR, Karafa MT, Mascha EJ, Krajewski LP, Beven EG. Reoperation for recurrent carotid stenosis: early results and late outcome in 199 patients. J Vasc Surg. 2001;34(1):5–12.

    Article  CAS  PubMed  Google Scholar 

  45. Oszkinis G, Pukacki F, Juszkat R, Weigele JB, Gabriel M, Krasinski Z, et al. Restenosis after carotid endarterectomy: incidence and endovascular management. Interv Neuroradiol. 2007;13(4):345–52.

    Article  CAS  PubMed  Google Scholar 

  46. EC/IC Bypass Study Group. Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. Results of an international randomized trial. N Engl J Med. 1985;313(19):1191–200.

    Article  Google Scholar 

  47. Day AL, Rhoton AL Jr, Little JR. The extracranial-intracranial bypass study. Surg Neurol. 1986;26(3):222–6.

    Article  CAS  PubMed  Google Scholar 

  48. Grubb RL Jr, Derdeyn CP, Fritsch SM, Carpenter DA, Yundt KD, Videen TO, et al. Importance of hemodynamic factors in the prognosis of symptomatic carotid occlusion. JAMA. 1998;280(12):1055–60.

    Article  PubMed  Google Scholar 

  49. Vilela MD, Newell DW. Superficial temporal artery to middle cerebral artery bypass: past, present, and future. Neurosurg Focus. 2008;24(2):E2.

    Article  PubMed  Google Scholar 

  50. Powers WJ, Clarke WR, Grubb RL Jr, Videen TO, Adams HP Jr, Derdeyn CP, et al. Extracranial-intracranial bypass surgery for stroke prevention in hemodynamic cerebral ischemia: the Carotid Occlusion Surgery Study randomized trial. JAMA. 2011;306(18):1983–92.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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Correspondence to M. Yashar S. Kalani .

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Norat, P., Soldozy, S., Park, M.S., Kalani, M.Y.S. (2020). Carotid Endarterectomy. In: Park, M., Kalani, M., de Havenon, A., McNally, J. (eds) Carotid Artery Disease. Springer, Cham. https://doi.org/10.1007/978-3-030-41138-1_6

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  • DOI: https://doi.org/10.1007/978-3-030-41138-1_6

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