Chapter 35. Carotid Endarterectomy

• 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 ...