Perioperative Stroke
The perioperative stroke rate after carotid bifurcation endarterectomy is 1–3 %, in specialized centers < 1%.
1. Clamping Ischemia of the CCA with Insufficient Intracranial Collateral Supply (Circle of Willis)
- awake patient (regional anesthesia): neurological symptoms such as unconsciousness, loss of speech, paralysis, restlessness
- sleeping patient (general anesthesia): e.g., non-pulsatile dark red backflow, significant changes in EEG or SSEP (somatosensory evoked potentials) to below 50 % of baseline despite adequate blood pressure, significant drop in flow velocity in the middle cerebral artery
- Recommendation: Before clamping the CCA, weight-adapted 3000 – 5000 IU heparin i.v.
- → Insertion of a lumen-adapted shunt from the common carotid artery into the internal carotid artery
2. Insufficient Reconstruction with Flow Turbulences
- Cause: remaining plaque parts, elongations, kinking stenoses, distal step in eversion TEA
- Consequence: turbulent flow leads to coagulation activation (platelet clotting)
- can result in perioperative strokes and early occlusions
- Prophylaxis: technically flawless reconstruction, additional anticoagulation with 3000 –5000 IU heparin i.v. prevents thrombus formation
- intraoperative angiography for quality control
- → surgical revision/mechanical recanalization
- → immediate postoperative intra-arterial lysis provided cerebral hemorrhage is reliably excluded (imaging!); systemic lysis immediately postoperatively is generally contraindicated
3. Embolization due to Mobilization of Plaque Material during the Preparation Phase
- Prophylaxis: subtle preparation in no-touch technique
- → surgical revision/mechanical recanalization, if necessary endovascular
4. Inadequate Flushing of All Inflowing and Outflowing Vessels to Flush Out Stasis Clots
- → surgical revision/mechanical recanalization
5. Clamp Damage to the Intima in Severe Sclerosis of the Supplying Common Carotid Artery
- local dissection remains unrecognized
- can lead to thromboembolisms
- → surgical revision/mechanical recanalization