Carotid Endarterectomy

Definition

Carotid endarterectomy is a surgical procedure to treat obstruction of the carotid artery caused by atherosclerotic plaque formation.

Purpose

The purpose of surgical therapy for vascular disease is to prevent stroke. Stroke can be caused by atherosclerosis of the carotid arteries located in the neck. Atherosclerosis is a degenerative disease of the cardiovascular system, which can occur in the carotid arteries in the neck, resulting in plaques of lipids, cholesterol crystals, and necrotic cells. The plaques in the carotid arteries can result in disease by embolizing, thrombosing, or causing stenosis (narrowing of artery). The plaques in the carotid arteries can cause disease if they obstruct a vessel or get dislodged and obstruct another area.

Precautions

The procedure is contraindicated in patients with an occluded carotid artery and in cases of severe neurologic deficit resulting from cerebral infarction. Additionally, the procedure is not performed in persons with concurrent medical illness severe enough to limit life expectancy. During the operation, precautions should be taken to prevent intraoperation movement of the atherosclerotic plaque. This can occur by excessive manipulation of the carotid bifurcation (the anatomical point where the internal and external carotid is joined together). The internal carotid will extend from the neck and penetrate the brain (to provide the brain with blood), whereas the external carotid will form other smaller arteries to provide blood to structures within the neck region. Atherosclerotic plaques are fragile especially if they are ulcerated. During the operation the surgeon must carefully dissect free other attached vessels such as the common carotid, internal carotid, and external carotid arteries with minimal physical manipulation of the affected carotid vessel.

Description

The first successful carotid endarterectomy was performed by DeBakey in 1953. During the past 40 years the procedure has been optimized and has become the most frequently performed peripheral vascular operation in the United States. There are more than 130,000 cases of carotid endarterectomy performed annually in the United States. Several randomized prospective clinical trials have conclusively established both the safety and efficacy of carotid endarterectomy and its superiority for favorable outcomes when compared to the best medical management. Largely due to credible scientific and clinical research, there has been a very large increase in the performance of this procedure over the past ten years. It is understandable that the procedure is common since it is utilized for the treatment of stroke, which is a condition that is associated with high morbidity (death rates) and is frequent. Carotid endarterectomy is the most common surgical procedure in the United States utilized to treat stenosis (narrowing) of the carotid artery. There are approximately more than 700,000 incident strokes annually and 4.4 million stroke survivors. There are 150,000 annual deaths from stroke. Approximately 30% of stroke survivors die within the first 12 months. Within 12 years approximately 66% will eventually die from stroke, making this condition the third leading cause of death in the United States. The cause of atherosclerosis is unknown, but injury to the arteries can occur from infectious agents, hyperlipidemia, cigarette smoking, and hypertension. The aggregate cost associated with approximately 400,000 first strokes in 1990 was $40.6 billion. Among those who have experienced one stroke, the incidence of stroke within five years is 40–50%. Research as of 2002 concludes that carotid endarterectomy remains the standard of care for the treatment of carotid artery atherosclerosis.

Surgical Description

A vertical incision is made in front of the sternocleidomastoid muscle providing optimal exposure of the surgical field. The line of the incision (10 cm in length) begins at the mastoid process and extends to approximately one to two fingerbreadths above the sternal notch. The exact location of carotid bifurcation can be determined before operation by ultrasound studies or arteriography. Muscles and nerves within the area are carefully displaced to allow access to the diseased area (plaque). When the surgical field is cleared of adjacent anatomical structures the endarterectomy portion of the procedure is carried out. This is accomplished by an incision in the common carotid artery at the site below the atherosclerotic plaque. The surgeon then uses an angled scissor (called a Potts scissor) to incise the common carotid artery through the plaque into the normal internal carotid artery. It is vital to extend the arterial incision (arteriotomy) above and below the atherosclerotic plaque. The surgeon utilizes a blunt dissecting instrument called a Penfield instrument to dissect the atherosclerotic plaque from the attachment to the arterial wall.

Arterial Reconstruction

After removing the atherosclerotic plaque, primary closure with sutures, or closure with a vein or prosthetic patch, is performed. Research indicates that utilization of a prosthetic patch is more favorable than suture closing. During this stage of the operation flushing is important to remove debris and air. Vein patch is advantageous because this type of closure reduces the risk of thrombus accumulation and possibly prevents perioperative stroke.

Preparation

As part of the preoperative preparation, routine laboratory tests for blood chemistry (complete blood count, electrolytes), kidney function tests, lipid profiles, and special blood tests to monitor clotting times are ordered by the clinician. Measurement of clotting times is important because blood thinner medications are typically given to patients preoperatively. Neuroimaging studies of the head are important in symptomatic patients to identify old or new cerebral infarcts. Carotid ultrasound studies are the screening test of choice accepted by surgeons to evaluate for carotid stenosis. An electrocardiogram (ECG) is important for evaluating past myocardial infarction and ischemic cardiac changes. The importance of ECG monitoring cannot be overemphasized given that the most common cause of postoperative mortality (death) is cardiac arrest. Positioning of the patient is also important. The operating table should be horizontal without head elevation. The head should be partially turned to the opposite side of the surgical field. It may be advantageous to place a rolled towel under the patient's shoulders to exaggerate neck extension. Gentle preparation and cleaning of operative fields should ensure minimal physical manipulation and pressure to avoid dislodging fragments of atherosclerotic plaque. The goals for anesthetic management include control of blood pressure and heart rate, protection of the brain and heart from ischemic insult, and relief of surgical pain and operative stress responses. Routine monitors (ECG and pulse oximetry to measure blood oxygen levels) and oxygen face mask are placed prior to anesthetic induction. Typically, any commonly utilized anesthetic and muscle relaxants (nondepolarizing) can be administered for carotid endarterectomy.

Aftercare

Aspirin therapy should be initiated at the time of diagnosis of transient ischemic attack (TIA), amaurosis fugax (transient visual loss), or stroke. Recent research from the prospective Aspirin and Carotid Endarterectomy (ACE) trial suggests that low dose (80 to 325 mg per day) of aspirin is optimal in preventing thromboembolic events after carotid endarterectomy. After carotid endarterectomy the patient's blood should be tested (complete blood count and electrolytes). Cardiac function can be monitored with ECG recordings. Frequent neurologic assessment is essential as well as hemodynamic monitoring (with the goal of maintaining blood pressure at its prior range). The patient should be observed for hemotoma formation which could cause airway obstruction. Antiplatelet therapy is necessary. About two weeks postoperatively patients are evaluated for neurologic and wound complications. Carotid ultrasound studies are performed after six months postoperatively and annually scheduled.

Risks

There are several important complications that can occur after carotid endarterectomy. Stroke or transient neurologic deficit can occur within 12 to 24 hours after operation. These conditions are usually caused by thromboembolic complications, which typically originate from the endarterectomy site or damaged vessels that were involved during the operative procedure (internal, common, and external carotid arteries). In approximately 33–50% of patients, hypertension or hypotension can occur. Wound complications such as hemotoma formation can cause pain and tracheal (wind pipe) deviation, which can impair normal breathing. During surgery, damage to vital nerves can occur, such as cervical nerves which supply sensation to the neck region. Patients may complain of numbness in the lower ear, lower neck, and upper face regions. Damage to the hypoglossal nerve (which provides innervations of the tongue), can produce deviation of the tongue to the paralyzed side and speech impairment. Additionally, the problem can reoccur, resulting in stenosis and symptoms.

Normal results

The normal progression of results following carotid endarterectomy is the prevention of stroke which is approximately 1.6% (two-year stroke risk), compared to 12.2% for patients who are medically treated. The results of the Asymptomatic Carotid Atherosclerosis Study (ACAS) reveal that the incidence of stroke for the postsurgical group (those receiving carotid endarterectomy) was 5.1%; for the group treated medically, the incidence was 11%. As with all surgical procedures, it is important for patients to select a surgeon who has expertise in the particular procedure and in the management of the condition. Some studies indicate that surgeons should perform 10 to 12 carotid endarterectomies every year in order to maintain surgical expertise and management skills.

BOOKS

Miller, Ronald D., et al, eds. Anesthesia. 5th ed. Churchill Living Stone, Inc. 2000.

Townsend, Courtney M. Sabiston Textbook of Surgery. 16th ed. W. B. Saunders Company, 2001.

PERIODICALS

Barnett, Henry J. M. "The appropriate use of carotid endarterectomy." Canadian Medical Association Journal 166 (April 2002): 9.

Gross, Cary, P. "Relation between prepublication release of clinical trial results and the practice of carotid endarterectomy." Journal of the American Medical Association 284 (December 2000): 22.

Mullenix, Philip. "Carotid Endarterectomy remains the gold standard." American Journal of Surgery 183, no. 59 (May 2002).

Perler, Bruce A. "Carotid Endarterectomy: The 'gold standard' in the endovascular era." Journal of the American College of Surgeons 194, no. 1 (January 2002).

Walker, Paul M. "Carotid Endarterectomy: applying trial results in clinical practice." Canadian Medical Association Journal 157 (1997).

ORGANIZATIONS

National Stroke Association. 9707 E. Easter Lane, Englewood, Colarado 80112. 303-649-9299 or 1-800-strokes; Fax: 303-649-1328. <http://www.stroke.org>.

Laith Farid Gulli, M.D.

Robert Ramirez, D.O.