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Carotid Endarterectomy

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

Background

The objective of carotid endarterectomy (CEA) is to prevent strokes. In the United States, stroke is the third leading cause of death overall and the second leading cause of death for women.[1] Among patients suffering a stroke, 50-75% had carotid artery disease (CAD) that would have been amenable to surgical treatment.

Several prospective randomized trials have compared the safety and efficacy of CEA with those of medical therapy in symptomatic and asymptomatic patients. Data from these prospective trials have confirmed that CEA offers better protection from ipsilateral strokes than medical therapy alone in patients presenting with either symptomatic or asymptomatic CAD.

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Indications

CEA should be considered for any patient with carotid artery stenosis in whom surgery will improve the natural history of the disease to a greater degree than the corresponding medical treatment would.[2]

In symptomatic good-risk patients with surgical morbidity and mortality (stroke and death) of less than 6%, proven indications for CEA include the following:

  • One or more transient ischemic attacks (TIAs) in the preceding 6 months and carotid artery stenosis exceeding 50% [3]

Acceptable but not proven indications include the following:

  • Ipsilateral TIA and carotid artery stenosis exceeding 70%, combined with required coronary artery bypass grafting (CABG)
  • Progressive stroke and carotid artery stenosis exceeding 70%

In asymptomatic good-risk patients treated by surgeons with surgical mortality and morbidity of less than 3%, the proven indication for CEA is stenosis exceeding 60%.[4]

Current American Heart Association (AHA)/American Stroke Association (ASA) guidelines for the prevention of stroke in patients with stroke or TIA contain the following new or updated recommendations relevant to CEA[5] :

  • Carotid angioplasty and stenting (CAS) is indicated as an alternative to CEA for symptomatic patients at average or low risk for complications associated with endovascular intervention when the diameter of the lumen of the internal carotid artery is reduced by >70% by noninvasive imaging or >50% by catheter-based imaging or noninvasive imaging with corroboration and the anticipated rate of periprocedural stroke or death is < 6% (class IIa; level of evidence B)
  • It is reasonable to consider patient age in choosing between CAS and CEA; for patients older than about 70 years, CEA may be associated with improved outcome CAS, particularly when the arterial anatomy does not favor endovascular intervention; for younger patients, CAS is equivalent to CEA in terms of risk for periprocedural complications and long-term risk for ipsilateral stroke (class IIa; level of evidence B)
  • CAS and CEA in the above settings should be performed by operators with established periprocedural stroke and mortality rates of < 6% for symptomatic patients (class I; level of Evidence B)
  • Routine, long term follow-up imaging of the extracranial carotid circulation with carotid duplex ultrasonography is not recommended (class III; level of evidence B)
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Contraindications

CEA is contraindicated if the patient’s general condition includes a serious illness that will substantially increase perioperative risk or shorten life expectancy. It is also contraindicated in patients who present acutely with a major stroke or in patients who experienced a major devastating stroke with minimal recovery or a significantly altered level of consciousness.

The traditional teaching was that emergency CEA in an acutely occluded carotid artery might convert an ischemic cerebral infarct to a hemorrhagic infarct, possibly resulting in death. The timing of the operation was considered optimal when the patient reached optimal recovery before elective CEA was performed. However, a few reports of improved neurologic outcomes with early intervention in patients with acute nonhemorrhagic strokes have emerged.[6] Careful patient selection is essential.

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Technical Considerations

A solid understanding of the anatomy of the carotid vessels and adjacent structures (see the image below) is critical for performing CEA effectively and minimizing complications.

Anatomy of internal carotid and vertebral arteries Anatomy of internal carotid and vertebral arteries.

The aortic arch provides the great vessels, including the innominate artery, the left common carotid artery (CCA), and the subclavian artery. In the most common configuration, the innominate artery branches into the right subclavian artery and the right CCA. Vertebral arteries branch off the subclavian arteries bilaterally.

On each side, the CCA travels within the carotid sheath before branching into the ipsilateral internal carotid artery (ICA) and external carotid artery (ECA). The ECA primarily supplies blood to the face and includes branches of the superior thyroid and ascending pharyngeal arteries. The ICA has no extracranial branches.

The carotid sinus is a baroreceptor located at the carotid bifurcation (where the CCA bifurcates into the ICA and the ECA) and is innervated by the nerve of Hering, a branch from cranial nerve IX (the glossopharyngeal nerve). The carotid bifurcation also contains the carotid body, which functions as a chemoreceptor responding to low oxygen levels or high carbon dioxide levels.

The ICA has an intracranial branch called the ophthalmic artery, which collateralizes and communicates with the external carotid blood supply. The ophthalmic artery is a common location for carotid emboli, which may result in transient monocular blindness (TMB) if they dissolve quickly or central retinal artery occlusion and blindness if they do not. The intracranial circle of Willis provides further communication between the ICA, the ECA, and the vertebrobasilar system.

For more information about the relevant anatomy, see Arterial Supply Anatomy, Arteries to the Brain and Meninges, and Circle of Willis Anatomy.

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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
  1. WHO. Surveillance in brief: Update of noncommunicable diseases and mental health surveillance activities. WHO. 2003. 5:1-5.

  2. Ricotta JJ, Aburahma A, Ascher E, Eskandari M, Faries P, Lal BK. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg. 2011 Sep. 54(3):e1-31. [Medline].

  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].

  6. Salem MK, Sayers RD, Bown MJ, Eveson DJ, Robinson TG, Naylor AR. Rapid access carotid endarterectomy can be performed in the hyperacute period without a significant increase in procedural risks. Eur J Vasc Endovasc Surg. 2011 Feb. 41(2):222-8. [Medline].

  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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