Carotid endarterectomy

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CEA

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NASCET:

CEA group: 9% stroke at 2 years

Medical group: 26% stroke at 2 years

ACAS: at 5 years, 11% in nonoperated patients and 5.1% in operated patients

Perioperative death and stroke should be less than 3-5%


Operative technique:

Position supine

Roll under ipsilateral shoulder

Rotate head 15 degrees

Dissect along anterior border of sternocleidomastoid muscle

Find internal jugular vein

Find common facial vein

Double ligate common facial vein

Retract int jugular laterally

Descendens Hypoglossi of the ansa cervicalis runs with the hypoglossal nerve for 2-3 cm, the n descends anterior to the to the internal carotid and common carotid arteries.

Identify hypoglossal nerve

Expose internal at least one cm beyond palpable plaque

Medial mobilization of the ansa cervicalis allows superomedial mobilization of the hypoglossal nerve

Occasioanlly need to divide the belly of the digastric to obtain further rostral exposure

Open carotid adventia and identify sup thyroid artery

Circumfrential dissection of involved vessels

Vessel loops

Lidocaine injection into nerve of Hering (in carotid sinus)to minimize baroreceptor response (results in bradycardia)

Heparin (100 U/KG)

Give pentobarb

Clamp internal carotid distally

Fogarty vasc clamp over common

Small clips to occlude superior thyroid and external

11 blade in common approx 1cm proximal to bifurcation

Potts

Plaque dissection begins at proximal half of the arteriotomy within common

Double tacking with double armed 6-0 prolene

Close using 6-0 prolene

Prior to last sutures the internal carotid is unclamped to release any debris or air bubbles

Following closure, clamps are removed in the following sequence: external carotid common carotid, internal carotid,

Gelfoam on suture and hold pressure

Closure: platysma and skin

When median nerve somatosensory evoked potentials are monitored during the surgical procedure, evidence of cross-clamp ischemia is based on prolongation of central conduction time or a 50% reduction in SEP amplitude.


Spetzler recommends CEA with barbiturate protection


Complications:

Ischemia

IC hemorrhage (.41%)

CN injuries: details pp 1185

Stenosis from sutures

Wound complications

MI

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