Complications - Dolichoarteriopathy – Severe kinking with luminal narrowing type I/III of the right internal carotid artery

Perioperative stroke

The rate of perioperative strokes after carotid endarterectomy is 1%–3%, in specialized centers <1%. 

1. Clamping ischemia of CCA in deficient intracranial collateral circulation (circle of Willis)

• alert patient (regional anesthesia): neurologic symptoms such as unconsciousness, loss of speech, paralysis, agitation
• sleeping patient (general anesthesia):  e.g. non-pulsating, dark red arterial return, significant changes in EEG or SSEP (somatosensory evoked potentials) to below 50% of baseline despite adequate blood pressure, significant decrease in velocity in the middle cerebral artery
• Recommendation: Before clamping the CCA administer intravenous heparin 3,000 IU - 5,000 IU (weight-adapted)
• -> Insert a lumen-adapted shunt from the common carotid into the internal carotid artery

2. Inadequate reconstruction with flow turbulence

• Caused by: Remaining plaque, elongations, stenotic kinking, distal step in eversion carotid endarterectomy (ECEA)
• Result: turbulent flow activates coagulation (platelet clotting)
• may lead to perioperative strokes and early occlusion
• Prevention: technically flawless reconstruction, supplementary anticoagulation with intravenous heparin 3,000 IU–5,000 IU prevents thrombus formation
• Intraoperative angiography for quality assurance
• -> operative revision/mechanical recanalization
• -> Immediate postoperative intraarterial lysis if cerebral bleeding is reliably ruled out (imaging!); immediate postoperative systemic lysis is contraindicated

3. Embolization by mobilizing plaque material during the dissection phase

• Prevention: subtle no-touch dissection
• -> operative revision/mechanical recanalization,  possibly by endovascular technique

4. Inadequate flushing of all afferent and efferent vessels to rinse out stasis clots

• -> operative revision/mechanical recanalization

5. Intimal clamping damage in severe sclerosis of the afferent common carotid artery

• Local dissection stays undetected
• May result  in thromboembolism
• -> operative revision/mechanical recanalization