Youmans Neurological Surgery

1. Carotid endarterectomy
350
Michael J. Link
Kelly D. Flemming
Fredric B. Meyer

2. Carotid endarterectomy
• North American Symptomatic Carotid Endarterectomy Trial (NASCET)
• European Carotid Surgery Trial (ECST)

3. Preoperative Evaluation
Symptomatic Patients
• TIA or minor stroke of the anterior
circulation
• Routine laboratory evaluation,EKG,
CXR, CT NC
• Screening : ultrasonography of
the carotid arteries
• Confirm : MRA
• CTA
Asymptomatic Patients
• Screening is not recommend
• Based on age, male sex, hypertension,
tobacco abuse, peripheral vascular
disease

4. Indications Based on Randomized Controlled Trials
:Symptomatic Patients
NASCET
North American Symptomatic Carotid Endarterectomy Trial
• Jan 1988 – Feb 1991
• 659 pt, 50 clinical center
• 50 CEA procedures/ 2 Yrs / mortality
rate < 6 %
• Within 120 days, < 80 Yrs, ICA stenosis
30 – 90 %
• 1.Aspirin, 1300 mg/day, and other
stroke reduction therapy as : 331
• 2.Surgery : CEA, 328
ECST
European Carotid Surgery Trial
• 12 European country, 1998
• 4018 pt,97 center
• Within 6 Mo
• 1.Surgery 1807
• 2.Medical 1211

5. Indications Based on Randomized Controlled Trials
:Symptomatic Patients
NASCET
North American Symptomatic Carotid Endarterectomy
Trial
• Greastest point narrowing / Beyond
the bulb
• Perioperative stroke : 5.8%
ECST
European Carotid Surgery Trial
• Greastest point narrowing / estimate
original diameter
• Combined outcome surgical event,
ipsilateral major ischemic strokes
• Perioperative stroke : 7.0%

6. Indications Based on Randomized Controlled Trials
:Symptomatic Patients
• Highly significant benefit in patients with high-grade (70% to 99%)
stenosis
• Moderate stenosis(50% to 69 %) group also revealed a statistical
benefit
• No benefit , stenosis less than 50 %
• Surgery within 2 weeks of the last symptom improved outcomes
relative to later surgery (especially in women)
• No increased operative risk when operating within 2 weeks of a
nondisabling hemispheric stroke

7. Summary indication
• Recently symptomatic carotid stenosis (preferably within 2 weeks of
the last symptom) of 70% to 99% in patients with a life expectancy of
at least 5 years if the expected perioperative risk is expected to be
less than 6%.
• Recently symptomatic carotid stenosis of 50% to 69% with the same
caveats as above, except that women were not shown to benefit
from CEA and should probably be managed medically.

8. Summary indication
• Asymptomatic patients between the ages of 40 and 79 years with
greater than 60% stenosis and no significant comorbid conditions
that might increase their perioperative risk or result in a life
expectancy of less than 5 years. The overall perioperative risk should
be less than 3%
• The benefit to women is controversial, and careful consideration has
to be given to recommending prophylactic CEA for female patients.

9. Technique
• Thor Sundt, Jr., M.D.
• The department of Neurologic Surgery at the Mayo Clinic
• More than 3000 CEAs
• Trained generations of residents in this technique

10. Positioning and Exposure
• GA
• EEG
• Supine position
• Head turn to opposite site, extension
• Curvilinear incision
• 1 cm below the tip of the mastoid, curves 1 cm
below the angle of the mandible,
and ends 1 cm above the sternoclavicular joint
• Skin, platysma, cervical fascia

11. Positioning and Exposure
• Not violate the parotid fascia
• Dissected anterior border of SCM from
cervical fascia
• Can palpate carotid system
• Open cervical fascia to expose common carotid artery
• Omohyoid m. : inferior extent
• Posterior belly of the digastric m. : superior extent

12. Positioning and Exposure
• Carotid bifurcation, ECA, ICA
• Common facial vein, running transversely
: double ligate and divided
• Hypoglosaal nerve : superficial to the
ECA and ICA, just below the digastric muscle
• Descendens hypoglossi : can be sacrificed
• Vagus N. or Descendens hypoglossi : deep to carotid system between
the carotid and the IJV
• Superior laryngeal n. : dysphagia post-op

13. Positioning and Exposure
• Standard fish hooks
• Soft vessel loops : CCA,
ECA(2 cm from it origin),
superior thyroid artery
• Great care when taking bifurcation and the proximal ICA : not
dislodge emboli

14. Exposure for a High Bifurcation or Plaque
• Above the C3 level, a plaque that extends high up the ICA
• More cephalad exposure
• Curved forward and inferior in the postauricular sulcus while skirting
the earlobe, and then ascend in the pretragal skin crease.
• Elevating posterior border of parotid gland
• Posterior belly of digastric muscle
• Hypoglossal n. deep and inferior
• Stylohyiod muscle
• Deeper stylomandibular ligament

15. Endarterectomy
• Adequate distal exposure of the
cervical ICA : crucial successful
completion of procedure
• Heparin 5000 IU IV : doubling of the activated clotting time
• Occlude tension on superior thyroid arteryECA
• Elevated SBP to 160-180 mmHG
• Fogarty clamp on proximal CCA( soft portion) : one click
• Curved 12 mm temporary sugita aneurysm clip place on distal ICA
• Blade no.11 for arteriotomy at mid CCA

16. Endarterectomy
• Endarterectomy at carotid bifurcation
• Small spatula
• Pott’s scissors
• Until normal intima seen
• Open temporary clip to observe
back flow

17. Endarterectomy
• Break point
• Carry proximal to CCA
• No natural break point proximally
• Made with Pott’s scissors

18. Endarterectomy
• Circumferentially dissected
• Vascular tape on ECA can be loosed
• ECA evert to allow more distal
dissection
• Once the plaque starts to thin out
• Grasp and removed

19. Shunt Placement
• Change in monitor 16-channel EEG ipsilateral to the occluded ICA
• Reliable indicator of ischemia
• Faster frequency of > 4 Hz by > 50%
• Increase in the amplitude of delta activity by 50%
• Internal Sundt shunt
• Proximal on the artery
• Distal on the artery
• EEG is not improve : distal emboli or occlusion
• Check backflow : if no  pass Fogarty balloon
catheter to see whether a clot

20. Patch Closure of the Arteriotomy
• Knitt Dacron patch
• Distal end trim to V
• Double-armed 5-0 Prolene suture
• Apex of patch and apex of arteriotomy
• Runnig stich
• 1 mm deep and 1 mm distal to previous stich
• Two step

21. Primary Closure of the Arteriotomy
• < 1% encounter : patch angioplasty not necessary
• 6-0 Prolene
• First : Distal to proximal ¾
• Second : Proximal to distal

22. Restoration of flow
• Before typing last suture
• Lower SBP to 130-150 mmHg
• Backbled ICA 8-10 s
• Fogary clamp on CCA : temporary open
• Suture last stich
• Relax tape on ECA and superior thyroid artery

23. Restoration of flow
• Remove aneurysm clip
• Typical occlusion time 30-60 min
• Very common for significant bleeding to
arise from suture : surgeon’s finger tip or irrigation with warm saline
• Gel foam
• Doppler US
• ICA : low-resistance sound
• ECA : brisk,high-resistance sound

24. Closure
• 10 French Jackson-Pratt drain
• Platysma : interrupted 2-0 vicryl
• Dermis : interrupted 3-0 vicryl
• Skin : running 4-0 vicryl

25. Postoperative care
• ASA(325) at night
• Off drain in the morning

26. Management of complication
• Strict BP to avoid hyperperfusion injury
• Sustain mABP raise 15 mmHG : RX with beta-blocker or vasodilator
• Post-op neurological decifit : CT brain NC
• If CT normal : Cerebral angiography,look for endarterctomy site
• Endarterectomy site normal and there is evidence of distal emboli :
heparin anticoagulant
• Acute occlusion of ICA : return to operating room
• Postoperative neck hematoma