Carotid Endarterectomy

<Surgery>

<Index>

 

 

 

Rationale

-  Surgical removal of atheromatous plaque from carotid artery

-  Relief or prevention of disease secondary to carotid artery stenosis

 

Features

- Symptomatic 70-99% stenosis NNT = 6 in 2yrs

- Symptomatic 50-69% stenosis NNT = 22 in 5yrs

 

Procedure

- May be performed under local or GA

-  Local allows neuro assessment intra-op

-  With GA EEG, etc. required to monitor

- May be perfomed via femoral artery cather or direct

- Direct

-  Internal, common & external carotid a. clamped

-  +/- bypass shunt to maintain cerebral perfusion

-  Lumen of internal carotid a. opened

-  Plaque removed

-  Artery stitched

- Femoral Artery Catheter

-  Balloon dilation

-  Carotid stent

-  Filter peri-op to prevent embolic stroke

 

 

Contraindications

- Complete internal a. obstruction

- Prev stroke on ipsilateral side w major sequelae

 

Complications

- Stroke

-  Perioperative Stroke 1-5%

-  Neuro defecit may develop at end of op or latent

-  Most delayed from thrombotic occlusion

-  Cerebral haemorrhage 0.25%

-  Day 5 post op onwards

-  Preceded by HTN, headache, convulsion

-  Mx: reduce BP, bed rest, analgesia

-  DDx by CT --> Mx

- Reperfusion Syndrome

- Baroreceptor Damage

-  Usually resolves in 24hrs

-  HTN

-  --> cerebral oedema, stroke

-  Hypotension +/- bradycardia

-  IV fluids +/- Atropine

- Haemorrhage or Haematoma

-  0.5% require reoperation to stop bleeding

-  Most within 24hrs (some 2-3/7)

-  May cause airway obstruction, ischaemic stroke, exsanguinations (death)

- Hypoglossal n. damage

-  Tongue fasciculations & deviation to affected side

- Restenosis 2-3%