Carotid Endarterectomy

Abstract

Particular attention has been focused on lesions at the level of the carotid artery bifurcation as most lesions (considered as the culprit lesions) develop preferentially at this site. Randomized trials have underscored the beneficial effects of treating the stenotic lesions of the carotid bifurcation, either by endovascular procedures or surgery. However, one should also consider associated facts when discussing the indications and the results of carotid endarterectomy (CEA) or carotid angioplasty and stenting (CAS): First, many of the studies were performed before the implementation of statin therapy and antiplatelet therapy and before the era of modern medical control of hypertensive disease and diabetes and the reduction of smoking. Second, diagnostic imaging offers a better mapping of the entire superior aortic system (including the intracerebral circulation) and plaque morphology, allowing for a better stratification of risk in the given patient and for a more precise and efficient therapy. Third, again diagnostic imaging allows the identification of silent brain ischemia in asymptomatic patients or in patients with uncharacteristic clinical signs and symptoms. This represents a particular category of patients who will benefit from CAS or CEA. Fourth, staged and/or combined (hybrid) procedures may be more advantageous and beneficial to selected patients, thus leaving less room for a direct comparison between the various types of therapeutic measures. Fifth, surgery and endovascular procedures represent heterogeneous procedures (i.e., various techniques and devices are used either indicated by patient’s disease or by center’s preference), and numerous aspects are overlooked when merely comparing CEA to CAS. Sixth, diagnostic and therapeutic efficiency and results are operator dependent and directly related to the personal experience and that of the center. Seventh, carotid stenotic-occlusive disease develops bilaterally; hence, the significance of a carotid stenosis must be evaluated and interpreted in the context of bilateral disease and taking into account the status and potential of compensatory collateral circulation. The natural history of carotid stenosis and eventual occlusion appears protean. Bilateral carotid occlusive disease increases the risk for complications during and after unilateral CEA [1]. Eighth, a particular category of patients have bilateral carotid stenoses and are symptomatic on the site with the lower-degree stenosis. This raises an important question: which side should be treated first – the symptomatic or the highest-degree stenosis? Or should a bilateral CEA be performed? This also depends on the status of the dominant hemisphere: is it on the symptomatic side or on the higher stenosis side? Ninth, the method of stenosis measurement (Fig. 11.1) is also different in the various studies performed: NASCET [2], ECST [3], and common carotid method [4, 5]. Further particulars and special situations regarding stenosis measurement, difficulties, and pitfalls are presented in Fig. 11.2.