Perioperative management - Left carotid bifurcation eversion endarterectomy (EEA) in symptomatic carotid bifurcation stenosis – Vascular Surgery - vascular surgery
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Indications
1. Asymptomatic carotid stenosis
Stenosis is classified as asymptomatic if there have been no stenosis-associated symptoms within the prior six months.
According to current guidelines, surgical desobliteration in asymptomatic carotid stenosis of least 60% may be recommended, provided that the perioperative risk of stroke is <3%. Moreover, patients should have a life expectancy of more than 5 years.
In asymptomatic carotid stenosis, patients with the following particular risk factors benefit from invasive treatment:
- Progressive stenosis under optimized medication including smoking cessation
- Occlusion of the contralateral internal carotid artery
- Contralateral symptomatic stenosis and ipsilateral high-grade asymptomatic stenosis
- Statin intolerance
- Adverse morphology of the carotid plaque, e.g., floating thrombi or ulcers
- Bleeding into plaque on MRI
- Microembolism in transcranial Doppler ultrasonography
- Silent infarction on CT or MR imaging
- Reduced cerebrovascular reserve
2. Symptomatic carotid stenosis
Symptomatic carotid stenosis with luminal narrowing of 50% or more should undergo surgery, with a perioperative risk of stroke of <6%.
Timing
- In TIA or non-disabling stroke, if possible within the first 2 weeks (ruptured plaque with increased rate of re-embolization and increased risk of stroke)
- In crescendo TIA (recurrent carotid-associated TIAs in ever shorter intervals) as emergent surgery for secondary prevention
- In stable patients with regressive neurological symptoms of manifest stroke as early as possible; preoperative MRI detection of impaired intracranial barrier and progressive bleeding mandatory; interdisciplinary indication!
Carotid stenosis staging
Stage I: Asymptomatic stenosis IA No high-grade contralateral stenosis/occlusion IB High-grade contralateral stenosis/occlusion Stage II: Reversible cerebral ischemia (<6 months) IIA Amaurosis fugax IIB Transient ischemic attack (TIA) (symptoms <24 h) Stage III Ischemic stroke >24 h with clinical restitution IIIA Crescendo TIA IIIB Acute/progressive stroke Stage IV Ipsilateral stroke < 6 months Rankin 0 No symptoms at all Rankin 1 No significant disability despite symptoms; able to carry out all usual duties and activities Rankin 2 Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance Rankin 3 Moderate disability; requiring some help, but able to walk without assistance Rankin 4 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance Rankin 5 Severe disability; bedridden, incontinent and requiring constant nursing care and attention Contraindications
- EEA is not suited for long stenosis of the internal carotid artery reaching far downstream; it is reserved for short stenosis close to the ICA origin
- Severe transmural calcification of the carotid bifurcation extending into the cranium
- History of neck dissection with radiotherapy
- Rarely morbid obesity with loss of neck contour
- Local florid infection, including ENT and dentistry
- Major cardiopulmonary comorbidity
- Severe neurological deficit requiring nursing care
Preoperative diagnostic work-up
Medical history
- Vascular risk factors Smoking, arterial hypertension, dyslipidemia, diabetes
Clinical neurological examination
- >90% of stenoses and occlusions of supraaortic vessels (ICA, vertebral artery, etc.) often remain clinically asymptomatic and are incidental findings during screening examinations or preoperative imaging studies
- Symptoms of a lesion in the vessels supplying the brain depend on the vessel involved, the course over time, and the prevailing collateral blood supply (e.g., via the cerebral arterial circle)
- Typical symptoms of impaired blood flow in the region supplied by the carotid artery (internal carotid artery) are:
→ Motor or sensory hemisyndrome (e.g. "hemiplegia")
→ Amaurosis fugax (transient unilateral blindness: opthalmic artery)
→ Cortical dysfunction (language, visuospatial perception)
→ Rather atypical: homonymous bilateral visual field impairment
- Important: Carotid artery auscultation is inadequate for stenosis detection!
Cardiology examination
- 30% of patients present with CHD requiring treatment
Color flow Doppler imaging
Ultrasonography of the extracranial vessels supplying the brain should always study all vessels in both the transverse and axial plane:
- Common carotid artery from proximal to carotid bifurcation
- Carotid bifurcation with the posterolateral origin of the ICA
- External carotid artery
- Segments V1 to V3 of vertebral artery
- Subclavian artery and axillary artery
Search for hemodynamically relevant plaques and their morphological description ( B-mode):
- Hyperechoic versus hypoechoic
- Homogeneous versus inhomogeneous
- Smooth versus irregular contour
Plaque parameters with unfavorable prognosis:
- Hypoechoic internal plaque structure
- Extended plaque >1 cm
- Plaque diameter >4 mm
- Axial pulsation of the distal plaque
By international agreement, stenoses should be quantified according to the NASCET criteria.
Contrast-enhanced MR angiography or alternatively, CT angiography
- Validation of the findings or for treatment planning
- Assessment of intracranial vessels and possible parenchymal lesions (prior cerebral infarctions)
Digital subtraction angiography (DSA) of the arteries supplying the brain (rarely required)
- Only if the noninvasive procedures have proved inconclusive resulting in therapeutic consequences
- Example: stenotic kinking not evident on MRI or CT scan
CT or MRI of the brain
- In symptomatic patients, parenchymal imaging prior to elective revascularization
- In asymptomatic patients, such imaging can provide important additional insight, e.g., evidence of clinically silent cerebral infarction
Chest x-ray
Laboratory panels
- Blood count
- Electrolytes
- Coagulation
- Kidney function parameters
- Liver function parameters
- Blood lipids
- Blood group
In all patients with arteriosclerotic carotid stenosis, other sequelae of arteriosclerosis (coronary artery disease [CAD], peripheral arterial occlusive disease [PAOD]) should be assessed!
Special preparation
- Mark affected side
- Have patient fast 2–6 hours as per department protocol
- Continue platelet inhibitors; in combined anticoagulation, decide case-by-case based on cardiac risk profile
Informed consent
General surgical risks
- Major bleeding, blood transfusions, transmission of hepatitis/HIV through allogeneic blood transfusions
- Allergy/intolerance
- Wound infection
- Thrombosis/embolism
- Skin/vascular/nerve damage, e.g. due to patient positioning
- Keloid
Procedure-specific risks
- Cerebrovascular disorder/stroke
- Impaired blood supply to the eyes and even blindness
- Injury to cervical nerves: Hoarseness; loss of voice; dysphagia and dyspnea; angular palsy; shoulder elevation palsy
- Secondary bleeding, hematoma-induced tracheal compression, emergency surgical decompression
- Injury to carotid body (glomus caroticum): arrhythmia, blood pressure fluctuation
- Cardiopulmonary complications: myocardial infarction, pneumonia, pulmonary embolism
- Hyperperfusion syndrome: seizures, neurological deficits, migraine-like headaches, cerebral edema/bleeding
- Suture aneurysm → re-operation
- Intraoperative angiography: contrast-induced renal failure
Risks specific to surgery with regional anesthesia (cervical plexus)
- Horner syndrome (drooping eyelid)
- Sensation of facial warmth, hoarseness, dyspnea
- Numbness of adjacent structures: brachial plexus, cervical spinal cord
Anesthesia
Positioning
Operating room setup
Special instruments and fixation systems
Postoperative Behandlung
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