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Carotid Endarterectomy Medication

  • Author: Omar Haqqani, MD; Chief Editor: Vincent Lopez Rowe, MD  more...
 
Updated: Dec 09, 2014
 

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

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Antidysrhythmics, Ib

Class Summary

Antidysrhythmic Ib agents increase the electrical stimulation threshold of the ventricle by suppressing automaticity of conduction.

Lidocaine hydrochloride (Xylocaine)

 

Lidocaine hydrochloride is a class IB antiarrhythmic that increases the electrical stimulation threshold of the ventricle, suppressing the automaticity of conduction through the tissue.

If sinus bradycardia develops, 1-2 mL of 1% lidocaine is injected into the tissues of the carotid bifurcation to correct reflex sympathetic bradycardia.

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Anticoagulants, Cardiovascular

Class Summary

Anticoagulants are required to reduce the risk of coronary or cerebrovascular thrombotic events.

Heparin

 

Heparin (5000-7000 U) is administered intravenously (IV). Heparin augments activity of antithrombin III and prevents conversion of fibrinogen to fibrin. It does not actively lyse but is able to inhibit further thrombogenesis. It prevents recurrence of a clot after spontaneous fibrinolysis.

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Antiplatelet Agents

Class Summary

These agents can be considered to help prevent future ischemic strokes. As with anticoagulation, aspirin is of unproven benefit in moyamoya disease; its use is considered empirical.

All patients resume their antiplatelet drugs, primarily aspirin, immediately after surgery; clopidogrel is given if aspirin is contraindicated. Maximal medical therapy, including statins and beta blockers, should be given.

Aspirin (Ecotrin, Ascriptin Maximum Strength, Ascriptin, Bayer Aspirin)

 

Aspirin's efficacy in preventing stroke relies on the inhibitory effect of aspirin on platelet function. This presumably helps to prevent thrombus formation and propagation.

Clopidogrel (Plavix)

 

Clopidogrel selectively inhibits adenosine diphosphate (ADP) binding to platelet receptor and subsequent ADP-mediated activation of glycoprotein GPIIb/IIIa complex, thereby inhibiting platelet aggregation.

Clopidogrel may have a positive influence on several hemorrhagic parameters and may exert protection against atherosclerosis, not only through inhibition of platelet function but also through changes in the hemorrhagic profile.

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Contributor Information and Disclosures
Author

Omar Haqqani, MD MidMichigan Health

Omar Haqqani, MD is a member of the following medical societies: American Association for the Advancement of Science, American Medical Association, New York Academy of Sciences, Sigma Xi, Society for Vascular Surgery, American Society of Clinical Oncology, American Federation for Clinical Research, American Venous Forum, Vascular and Endovascular Surgery Society, Eastern Vascular Society, Society for Clinical Vascular Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

Mark David Iafrati, MD RVT, FACS, Chief of Vascular Surgery, Director Center for Wound Healing, The Cardiovascular Center, Tufts Medical Center; Assistant Professor of Surgery, Tufts University School of Medicine; Assistant Professor of Surgery, Uniformed Services University of the Health Sciences

Mark David Iafrati, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association of Military Surgeons of the US, Massachusetts Medical Society, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Critical Care Medicine, Society of Laparoendoscopic Surgeons, American Venous Forum, Society for Clinical Vascular Surgery

Disclosure: Nothing to disclose.

James M Estes, MD Assistant Professor of Surgery, Tufts University School of Medicine; Medical Director of Vascular Laboratory, Attending Surgeon, Tufts Medical Center; Attending Surgeon, Morton Hospital

James M Estes, MD is a member of the following medical societies: American College of Surgeons, Association for Surgical Education, Society for Vascular Surgery, Eastern Vascular Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Society for Vascular Surgery, Vascular and Endovascular Surgery Society, Society for Clinical Vascular Surgery, Pacific Coast Surgical Association, Western Vascular Society

Disclosure: Nothing to disclose.

References
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  3. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. 1991 Aug 15. 325(7):445-53. [Medline].

  4. Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA. 1995 May 10. 273(18):1421-8. [Medline].

  5. Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014 Jul. 45(7):2160-236. [Medline].

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  7. Landis GS, Faries PL. A critical look at "high-risk" in choosing the proper intervention for patients with carotid bifurcation disease. Semin Vasc Surg. 2007. 20:199-204.

  8. Schechter MA, Shortell CK, Scarborough JE. Regional versus general anesthesia for carotid endarterectomy: the American College of Surgeons National Surgical Quality Improvement Program perspective. Surgery. 2012 Sep. 152(3):309-14. [Medline].

  9. Ricotta JJ, DeWeese JA. Is routine carotid ultrasound surveillance after carotid endarterectomy worthwhile?. Am J Surg. 1996 Aug. 172(2):140-2; discussion 143. [Medline].

  10. Lal BK, Beach KW, Roubin GS, Lutsep HL, Moore WS, Malas MB, et al. Restenosis after carotid artery stenting and endarterectomy: a secondary analysis of CREST, a randomised controlled trial. Lancet Neurol. 2012 Sep. 11(9):755-63. [Medline].

  11. Geraghty PJ, Brothers TE, Gillespie DL, Upchurch GR, Stoner MC, Siami FS, et al. Preoperative symptom type influences the 30-day perioperative outcomes of carotid endarterectomy and carotid stenting in the Society for Vascular Surgery Vascular Registry. J Vasc Surg. 2014 Sep. 60(3):639-44. [Medline].

  12. Bonati LH, Dobson J, Featherstone RL, Ederle J, van der Worp HB, de Borst GJ, et al. Long-term outcomes after stenting versus endarterectomy for treatment of symptomatic carotid stenosis: the International Carotid Stenting Study (ICSS) randomised trial. Lancet. 2014 Oct 14. [Medline].

  13. Ascher E, Markevich N, Schutzer RW, Kallakuri S, Jacob T, Hingorani AP. Cerebral hyperperfusion syndrome after carotid endarterectomy: predictive factors and hemodynamic changes. J Vasc Surg. 2003 Apr. 37(4):769-77. [Medline].

 
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Carotid endarterectomy: operative techniques.
Anatomy of internal carotid and vertebral arteries.
 
 
 
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