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How I do it: endarterectomy for carotid web

  • How I Do it - Vascular Neurosurgery - Other
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Abstract

Background

The carotid web is an important and under recognized etiology for recurrent cryptogenic strokes. A management option for a symptomatic carotid web is a carotid endarterectomy (CEA) with surgical microdissection and removal of the intimal luminal defect.

Methods

We describe some of the technical nuances involved in successfully performing a carotid endarterectomy for resection of a carotid web.

Conclusion

Utilizing a familiar approach to an understudied pathology, this procedure can be safely performed and provides the patient with lasting protection against recurrent infarcts through removal of the thromboembolic nidus.

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Author information

Authors and Affiliations

  1. Department of Neurosurgery, NYU Langone Health, 550 1st Ave, New York, NY, 10016, USA

    Rogelio Esparza, Julia R. Schneider & Erez Nossek

  2. Department of Neurology, Duke University School of Medicine, Durham, NC, USA

    Brian Mac Grory

Authors
  1. Rogelio Esparza
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  2. Julia R. Schneider
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  3. Brian Mac Grory
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  4. Erez Nossek
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Corresponding author

Correspondence to Erez Nossek.

Ethics declarations

Ethics approval and consent to participate

This article contains a N < 3 patients, so IRB approval was not required as per institutional policy. There is no patient identifying information, so consent was neither sought nor required.

Conflict of interest

The authors declare no competing interests.

Additional information

Key Points

1. Preoperative localization of the carotid bifurcation as well as the web in respect to the bifurcation for surgical planning

2. Confirmation with neuromonitoring, achieve baseline MEPS and SSEPS

3. Plan skin incision according to ultrasound localization of carotid web

4. Meticulous hemostasis throughout the neck dissection and exposure of the bifurcation

5. Clamping: internal carotid–common carotid–external carotid (I-C-E)

6. Linear arteriotomy at least 10 mm above and below the web

7. Do not attack the web directly, rather find a plan within the media of the vessel wall deep to the level of the web and circumferentially dissect the intima with the web in it.

8. Ensuring complete removal of any residual plaque/defect as most intraoperative strokes are secondary to thromboembolic events rather than cross-clamping.

9. Primary closure of the arteriotomy using 6-0 prolene sutures

10. Unclamping: with external carotid–common carotid (wait 1 min)–internal carotid (E-C-I)

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This article is part of the Topical Collection on Vascular Neurosurgery - Other

Supplementary information

Video 1

Circumferential dissection technique in carotid endarterectomy for carotid web resection (MP4 17551 kb)

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Esparza, R., Schneider, J.R., Grory, B.M. et al. How I do it: endarterectomy for carotid web. Acta Neurochir 163, 1763–1766 (2021). https://doi.org/10.1007/s00701-021-04841-z

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  • DOI: https://doi.org/10.1007/s00701-021-04841-z

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