Vascular: Carotid Endarterectomy (CEA)

Carotid Endarterectomy (CEA)

Basics

  • Open Surgery to Remove Carotid Plaque
  • Goal: Prevent Future Stroke

Positioning

  • Neck Extended & Rotated to Contralateral Side
  • Arms at Side

Procedure

  • Initial Incision
    • Standard: Longitudinal Along Medial Sternocleidomastoid Muscle (SCM)
    • Transverse: 1-2 cm Below Angle of Jaw
      • Technically May Be More Difficult
      • Primarily for Cosmesis
  • Expose Carotid Sheath
    • Divide Platysma
    • Mobilize Medial Border of SCM
      • Avoid Injury to External Jugular Vein
      • Avoid Injury to Greater Auricular Nerve
  • Enter Carotid Sheath
    • Minimize Carotid Artery Manipulation (Embolization Risk)
    • Dissect Medial Border of Internal Jugular Vein (IJV)
      • Divide Facial Vein (Seen Crossing Medially)
    • Retract IJV Laterally
    • Identify Vagus Nerve (Between IJV & Carotid; May Lie Anteriorly)
  • Dissect Carotid Artery
    • Identify Common Carotid Artery (CCA), External Carotid Artery (ECA) & Internal Carotid Artery (ICA)
      • Dissect ICA Past Area of Stenosis
      • Avoid Injury to Carotid Body at Bifurcation
    • Identify Structures
      • Ansa Cervicalis (Medial to CCA)
      • Superior Thyroid Artery (Off Proximal ECA)
      • Hypoglossal Nerve (Superior Extent)
    • Control Inflow & Outflow Circumferentially
      • CCA with Umbilical Tape & Rummel’s Tourniquet
      • Superior Thyroid Artery with Vessel Loops
        • Or Tie
      • ECA & ICA with Vessel Loops
  • Clamping Mn
    • First Administer 70-100 U/kg Heparin
      • Allow 3 Minutes Circulation
    • First Clamp ICA (Prevent Embolization)
      • Ensure on Normal Portion of Artery Distal to Plaque
    • Then Clamp CCA
    • Then Clamp ECA Last
  • Preform Endarterectomy
  • Close
    • Close Platysma
    • Close Skin

CEA Incision 1

Clamping (I.C.E.) 1

Conventional Endarterectomy

  • Vertical Arteriotomy
    • From CCA into ICA
  • If Shunt Used:
    • First Place into Distal ICA & Back Bled
    • Then Proximal End Placed into CCA
  • Endarterectomy
    • Begin in CCA (Between Media & Adventitia)
      • Remove Intima and Part of Media
    • Continue into ICA
      • #1 Concern: Ensure a Good Distal End Point
      • Endpoint at Normal Intima with Gradual Tapering
    • Extend into ECA Orifice with Gradual Tapering
  • Close with Patch (Autologous, PTFE, Dacron or Bovine)
    • Prior to Closure: Vessels Bled & Site Irrigated with Heparinized Saline
    • *In General Patch Represents Standard of Care Although Some Now Suggest Selective Patching if Diameter ≥ 6 mm (Debated)
  • Release Clamps
    • First Release ICA Clamp Briefly to Back Bleed
      • Then Replace
    • Then Release Clamps on ECA and CCA (Remaining Air/Debris to ECA)
    • Finally Remove ICA Clamp

Conventional Endarterectomy 1

Patch Angioplasty 1

Eversion Endarterectomy

  • Completely Transect the ICA at the Bifurcation
  • Adventitia is Then Everted Circumferentially (“Circumcised”) Back Off the Carotid Plaque
  • Plaque Then Removed from the Common Carotid
  • ICA Re-Anastomosed to the Bifurcation by Simple End-to-End Anastomosis
    • No Patch Required
  • *Similar Results/Complications Between Conventional & Eversion Techniques

Eversion Arterial Transection 1

Eversion Endarterectomy 1

Eversion Closure 1

Bilateral Repairs

  • First Repair: Side with Greatest Stenosis
    • If Equal: Dominant Side First
  • Before Advancing to Second Contralateral Side: Verify Intact Ipsilateral Side

Carotid Endarterectomy (CEA) – Complications

Perioperative Stroke

  • Often from Residual Flap or Thrombosis
  • Mostly Reversible to Flow Restored within 1-2 Hours
  • Management:
    • Intraoperative (Waking in OR): Reexplore
    • Postoperative: Will Likely Require Reexploration in OR
      • Consider Duplex US if Rapidly Available
      • If US Negative: CT Head (Rule Out Hemorrhage)

Restenosis

  • Risk: 5-20%
  • Causes:
    • Immediate (< 4 Weeks): Technical Error
    • Early (1 Month-2 Years): Myointimal Hyperplasia
    • Late (> 2 Years): Recurrent Atherosclerosis
  • Treatment:
    • Asymptomatic: Conservative Management
    • Symptomatic: Stent vs Repeat CEA

Myocardial Infarction (MI)

  • Most Common Non-CVA Morbidity
  • Causes 25-50% of Perioperative Deaths

Cranial Nerve Injury (CNI)

  • Most Are Transient & Resolve After a 3-4 Weeks
  • Risk of Injury: 5-20%
    • Risk of Permanent Injury: 0-1%
  • Most Common Injury: Vagus (#1) & Hypoglossal (#2)
    • Most Injuries are Transient
  • Specific Nerve Injuries:
    • Hypoglossal Nerve
      • Lies Just Above the Bifurcation
      • Presentation: Speech & Mastication Deficit
      • Tongue Deviates to Ipsilateral Side of Injury
    • RLN/Vagus
      • The Most Dangerous Nerve Injury
      • Lies Within the Carotid Sheath
      • Presentation: Hoarseness
      • Typically from Vascular Clamping
    • Glossopharyngeal
      • Rare; Most Common with High Dissections
      • Presentation: Swallowing Difficulty
    • Ansa Cervicalis
      • Presentation: Strap Muscle Deficits
    • Facial Nerve (Marginal Mandibular Branch)
      • Presentation: Smiling Deficit
        • From Corner of Mouth Retraction
      • Typically from Excessive Superior Retraction
    • Greater Auricular Nerve
      • Presentation: Numb Earlobe

Cerebral Hyperperfusion Syndrome

  • Impaired Autoregulation of Cerebral Perfusion After Chronic Hypoperfusion
  • Risk: 0.3-1.0%
  • High Mortality (75-100%)
  • Risk Factors:
    • Preoperative High-Grade Stenosis
    • Postoperative Hypertension
    • Bilateral Staged
  • Presentation:
    • Hypertension
    • Ipsilateral Frontal Headache
    • Stroke & Seizure
  • Tx: Antihypertensives & Anti-Seizure Meds

Postoperative Hematoma

  • Risk: 1-3%
  • Mostly from Diffuse Oozing
  • Creates a Risk Tracheal Compression & Airway Loss
  • Treatment: Emergent Intubation & Open in OR
    • *Open at Bedside (As in Thyroidectomy) Only in an Absolute Emergency – Possibility of Graft Blowout that Needs Repair in OR

Pseudoaneurysm

  • Presents as a Pulsatile Mass
  • Treatment: Surgical Repair
    • Drape/Prep Before Intubation

Carotid Body Injury

  • Presentation: HTN
  • Treatment: Nitroprusside (Avoid Bleeding)

Mnemonics

Clamping Order for CEA

  • “ICE”
    • ICA (First)
    • CCA (Second)
    • ECA (Last)
  • Unclamp in the Opposite Order

References

  1. Chiesa R, Melissano G, Castellano R, Tshomba Y, Marone EM, Civilini E, Astore D, Calliari F, Catenaccio B, Coppi G, Carozzo A, Mennella R. Carotid Endarterectomy: experience in 8743 cases. HSR Proc Intensive Care Cardiovasc Anesth. 2009;1(3):33-45. (License: CC BY-NC-3.0)