Perioperative management - Left carotid bifurcation eversion endarterectomy (EEA) in symptomatic carotid bifurcation stenosis – Vascular Surgery

  1. 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%.


    • 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
    IANo high-grade contralateral stenosis/occlusion
    IBHigh-grade contralateral stenosis/occlusion
    Stage II:Reversible cerebral ischemia (<6 months)
    IIAAmaurosis fugax
    IIBTransient ischemic attack (TIA) (symptoms <24 h)
    Stage IIIIschemic stroke >24 h with clinical restitution
    IIIACrescendo TIA
    IIIBAcute/progressive stroke
    Stage IVIpsilateral stroke < 6 months
    Rankin 0No symptoms at all
    Rankin 1No significant disability despite symptoms; able to carry out all usual duties and activities
    Rankin 2Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance
    Rankin 3Moderate disability; requiring some help, but able to walk without assistance
    Rankin 4Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance
    Rankin 5Severe disability; bedridden, incontinent and requiring constant nursing care and attention
  2. 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
  3. 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!

  4. 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
  5. 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

General anesthesiaRegional anesthesia (cervical plexus) in cooperative patients; not in extremely h

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