Skip to Main Content

++

  • Asymptomatic carotid stenosis > 60% by angiography or 70% by duplex ultrasound.
  • Symptomatic carotid stenosis (cerebrovascular accident, transient ischemic attack, or amaurosis fugax) > 50%.
  • Carotid endarterectomy can be performed safely under regional anesthesia in patients with severe chronic obstructive pulmonary disease, coronary artery disease (CAD), and other comorbidities.
  • Carotid stenting can be considered in patients with a history of neck irradiation, modified radical neck dissection, or reoperative carotid endarterectomy.
  • Only patients with concurrent symptomatic carotid stenosis and symptomatic CAD should be considered for combined carotid endarterectomy and coronary artery bypass grafting.

++

  • There are no absolute contraindications other than distal internal artery occlusion.

++

Expected Benefits

++

  • Long-term stroke prevention.

++

Potential Risks

++

  • The risk of perioperative stroke is ≤ 1.5% in expert series.
  • The risk of a clinically significant cranial nerve injury is similarly small in experienced hands and includes:
    • Injury to the hypoglossal nerve with tongue deviation toward the operative side.
    • Injury to the vagus nerve or a nonrecurrent laryngeal nerve (which may result in ipsilateral vocal cord paralysis).
    • Superior laryngeal nerve injury (which may result in difficulty speaking at high pitch).
    • A retraction injury to the marginal mandibular branch of the facial nerve (which may result in a lower facial droop).
  • Glossopharyngeal nerve injury (a concern in exposures approaching the skull base).
    • Spinal accessory nerve injury (a risk only if dissection is not conducted anterior to the internal jugular vein).
    • Other complications include myocardial infarction, postoperative bleeding requiring reexploration, wound infection, local sensory loss, and restenosis.
  • It should be emphasized that regular postoperative surveillance by duplex ultrasound is required to monitor for restenosis.

++

  • No special equipment is required.
  • A small, self-retaining retractor such as the "mini" Omnitract may be helpful, particularly if high exposure is necessary.
  • We prefer to control the distal internal carotid artery with an atraumatic clip (eg, Schwartz, Yasargil, or Heifetz).

++

  • Duplex ultrasound is highly sensitive and specific and is the only preoperative imaging required in most cases.
  • Arteriography (conventional or CT) is generally reserved for cases involving restenosis, a history of radiation or prior neck dissection, or atypical findings on duplex ultrasonography.

++

  • The patient should be in a semi-seated position with a small roll across the shoulder blades.
    • This allows for gentle extension and external rotation of the head to the contralateral side.
  • The ipsilateral arm is tucked, padding the elbow and wrist.
  • Care should be taken not to over-rotate or extend the head to avoid kinking of the vertebral arteries or contralateral carotid artery.
  • Landmarks such as the ear lobe, angle of the mandible, mastoid process, sternal notch, and clavicle must be included in the prepared area.

++

  • Carotid endarterectomy can be performed under regional anesthesia, general anesthesia with routine shunting, or general anesthesia with selective shunting based on adjuncts such as intraoperative EEG monitoring or stump pressures.
  • Figure 35–1: Most surgeons prefer an oblique ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessSurgery Full Site: One-Year Subscription

Connect to the full suite of AccessSurgery content and resources including more than 160 instructional videos, 16,000+ high-quality images, interactive board review, 20+ textbooks, and more.

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessSurgery

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.