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Carotid Endarterectomy Periprocedural Care

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

Preprocedural Evaluation

Carotid artery disease (CAD) may be symptomatic or asymptomatic. Symptoms include transient ischemic attack (TIA), stroke, stroke in evolution, or crescendo TIA. In symptomatic patients, imaging should begin with carotid duplex ultrasonography. Carotid duplex imaging uses qualitative and quantitative information to determine the severity of carotid artery stenosis with an overall accuracy of 80-97%.

If duplex imaging demonstrates severe stenosis or ulcerative plaque that correlates with clinical symptoms, no further carotid imaging is required in most cases. In patients with mild-to-moderate disease (< 50%) on duplex imaging and hemispheric TIAs, alternative causes may be sought with magnetic resonance angiography (MRA), computed tomographic angiography (CTA), or catheter-based angiography of the chest, neck, and brain. These advanced imaging techniques may also be indicated for operative planning in the following situations[7] :

  • Low carotid lesion (suggested by low common carotid artery [CCA] velocities)
  • High carotid lesion (above C2)
  • Previous carotid endarterectomy (CEA)
  • History of other major neck operation (eg, radical neck dissection, laryngectomy, or tracheostomy)
  • Cervical fusion
  • Poor neck mobility
  • Previous neck irradiation
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Patient Preparation

Anesthesia

Patients undergoing CEA are kept on nil per os (nothing by mouth) status from midnight the day before surgery.

Regional anesthesia using deep or superficial cervical blocks is commonly performed and allows direct observation of the patient for signs of cerebral ischemia, thereby reducing the need for intraoperative carotid shunting. However, use of regional anesthesia is contraindicated if either the patient or the surgeon has issues with anxiety or communication. Local anesthetic techniques result in less blood pressure lability.

Overall morbidity and mortality are not significantly affected by the choice of anesthetic technique. Although the type of anesthesia used for CEA does not impact outcomes, regional anesthesia is associated with shorter operative times, anesthetic times, and time to discharge.[8]

The main alternative to regional anesthesia in this setting is general anesthesia. General anesthesia has the advantage of reducing cerebral metabolic demand and increasing cerebral blood flow. Endotracheal intubation also provides good airway control and reduces patient and physician anxiety. Nasotracheal intubation can be used to facilitate exposure of the distal cervical segment of the internal carotid artery (ICA) in patients with high carotid artery stenosis or in patients undergoing reoperation.

Antiplatelet therapy should be continued throughout the perioperative period. Perioperative use of vasopressors or vasodilators to maintain blood pressure in the patient’s optimal physiologic range is critical.

Positioning

The patient is placed in the supine position with the head turned away from the side of the operation. A beach chair configuration offers greater comfort to awake patients and provides excellent exposure while decreasing venous pressure. The neck is moderately extended by placing a shoulder roll or by tilting back the neck extension of the bed.

The endarterectomy site is prepared and draped from the midline in an area encompassing the clavicle, the sternal notch, and the mandible. Proper lighting is essential, and loupe magnification is routine.

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Monitoring and Follow-up

As a rule, if no complication occurs, patients are discharged home on postoperative day 1. They continue their antiplatelet and secondary preventative therapy.

At 2-6 weeks after CEA, carotid duplex ultrasonography should be performed. If the findings from duplex imaging are satisfactory, another duplex study should be done 6 months to 1 year later, then every year thereafter. If there is evidence of moderate contralateral disease or recurrent carotid artery stenosis, scanning may be performed at intervals of 6-12 months.[9]

In the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), restenosis and occlusion occurred infrequently and rates were similar after CEA and carotid artery stenting during 2 years of follow-up. Female sex, diabetes, and dyslipidemia independently predicted restenosis or occlusion after the two procedures, and smoking predicted an increased rate of restenosis in patients who underwent CEA but not in those who underwent carotid artery stenting.[10]

In a retrospective review of Society for Vascular Surgery Vascular Registry database subjects who underwent CEA or carotid artery stenting from 2004 to 2011, Geraghty et al found that the 30-day outcomes of both procedures were significantly affected by the type of symptom presentation.[11] Presentation with stroke and TIA predicted higher rates of periprocedural complications, whereas TMB presentation with transient monocular blindness (TMB) predicted a periprocedural risk profile similar to that of asymptomatic disease.

Long-term data from the randomized International Carotid Stenting Study (ICSS) comparison of carotid stenting and CEA in patients with symptomatic carotid stenosis indicate that the two procedures are comparable with respect to long-term functional outcome and risk of fatal or disabling stroke.[12]

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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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