Information about Carotid Endarterectomy
Carotid endarterectomy (CEA) is a surgical procedure used to correct carotid stenosis (narrowing of the carotid artery lumen by atheroma), used particularly when this causes medical problems, such as transient ischemic attacks (TIAs) or cerebrovascular accidents (CVAs, strokes). Endarterectomy is the removal of material on the inside (end-) of an artery. Angioplasty and stenting of the carotid artery are undergoing investigation as alternatives to carotid endarterectomy.
Non-invasive procedures have been developed, by threading catheters through the femoral artery, up through the aorta, then inflating a balloon to dilate the carotid artery, with or without a wire-mesh shunt. The safety and effectiveness of these procedures is controversial. In the SAPPHIRE study, Yadav concluded that this procedure, known as carotid stenting, was non-inferior to carotid endarterectomy in total adverse events, and lowered event rates for major stroke, cranial nerve palsy, and myocardial infarction, in patients at high risk for surgery.[1] However, Cambria concluded that the study was not sufficiently powered to detect differences in stroke and death, and final conclusions must await larger trials.[2]
The aim of CEA is to prevent the adverse sequelae of carotid artery stenosis secondary to atherosclerotic disease, i.e. stroke. As with any prophylactic operation, careful evaluation of the relative benefits and risks of the procedure is required on an individual patient basis. Peri-operative combined mortality and major stroke risk is 2 – 5%.
Carotid stenosis is diagnosed with ultrasound doppler studies of the neck arteries or magnetic resonance arteriography (MRA). The circle of Willis typically provides a collateral blood supply. Symptoms have to affect the other side of the body; if they do not, they may not be caused by the stenosis, and arterectomy it will be of minimal benefit.
The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST) are both large randomized class 1 studies which have helped define current indications for carotid endarterectomy. The NASCET found that for every six patients treated, one major stroke would be prevented at two years (i.e. a “number needed to treat” (NNT) of six) for symptomatic patients with a 70 – 99% stenosis. Symptomatic patients with less severe carotid occlusion (50 – 69%) had a smaller benefit, with a NNT of 22 at five years (Barclay). In addition, co-morbidity adversely affects the outcome; patients with multiple medical problems have a higher post-operative mortality and hence benefit less from the procedure. The European asymptomatic carotid surgery trial (ACST) found that asymptomatic patients may also benefit from the procedure, but only the group with a high grade stenosis (greater than 75%). For maximum benefit patients should be operated on soon after a TIA or stroke, preferably within the first month.
Procedure
The internal, common and external carotid arteries are clamped, the lumen of the internal carotid artery is opened, and the atheromatous plaque substance removed. The artery is closed, hemostasis achieved, and the overlying layers closed. Many surgeons lay a temporary shunt to ensure blood supply to the brain during the procedure. The procedure may be performed under general or local anaesthesia. The latter allows for direct monitoring of neurological status by intra-operative verbal contact and testing of grip strength. With general anaesthesia indirect methods of assessing cerebral perfusion must be used, such as electroencephalography (EEG), transcranial doppler analysis and carotid artery stump pressure monitoring. At present there is no good evidence to show any major difference in outcome between local and general anaesthesia.Non-invasive procedures have been developed, by threading catheters through the femoral artery, up through the aorta, then inflating a balloon to dilate the carotid artery, with or without a wire-mesh shunt. The safety and effectiveness of these procedures is controversial. In the SAPPHIRE study, Yadav concluded that this procedure, known as carotid stenting, was non-inferior to carotid endarterectomy in total adverse events, and lowered event rates for major stroke, cranial nerve palsy, and myocardial infarction, in patients at high risk for surgery.[1] However, Cambria concluded that the study was not sufficiently powered to detect differences in stroke and death, and final conclusions must await larger trials.[2]
Indications
Surgical intervention to relieve atherosclerotic obstruction of the carotid arteries was first performed at St. Mary’s Hospital, London, in 1954. Since then, evidence for it’s effectiveness in different patient groups has accumulated. In 2003 nearly 140,000 carotid endarterectomies were performed in the USA (Halm).The aim of CEA is to prevent the adverse sequelae of carotid artery stenosis secondary to atherosclerotic disease, i.e. stroke. As with any prophylactic operation, careful evaluation of the relative benefits and risks of the procedure is required on an individual patient basis. Peri-operative combined mortality and major stroke risk is 2 – 5%.
Carotid stenosis is diagnosed with ultrasound doppler studies of the neck arteries or magnetic resonance arteriography (MRA). The circle of Willis typically provides a collateral blood supply. Symptoms have to affect the other side of the body; if they do not, they may not be caused by the stenosis, and arterectomy it will be of minimal benefit.
The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST) are both large randomized class 1 studies which have helped define current indications for carotid endarterectomy. The NASCET found that for every six patients treated, one major stroke would be prevented at two years (i.e. a “number needed to treat” (NNT) of six) for symptomatic patients with a 70 – 99% stenosis. Symptomatic patients with less severe carotid occlusion (50 – 69%) had a smaller benefit, with a NNT of 22 at five years (Barclay). In addition, co-morbidity adversely affects the outcome; patients with multiple medical problems have a higher post-operative mortality and hence benefit less from the procedure. The European asymptomatic carotid surgery trial (ACST) found that asymptomatic patients may also benefit from the procedure, but only the group with a high grade stenosis (greater than 75%). For maximum benefit patients should be operated on soon after a TIA or stroke, preferably within the first month.
Contra-indications
The procedure cannot be performed in case of:- Complete internal carotid artery obstruction (because the intraluminal thrombus then extends too far downstream, well into the intracranial portion of the artery, for endarterectomy to be successful).
- Previous stroke on the ipsilateral side with heavy sequelae, because there is no point in preventing what has already happened.
- Patient deemed unfit for the operation by the anaesthesiologist.
Complications
About 3% of patients will suffer neurological complications as a result of the procedure. Hemorrhage of the wound bed is potentially life-threatening, as swelling of the neck due to hematoma could compress the trachea. Rarely, the hypoglossal nerve can be damaged during surgery. This is likely to result in fasiculations developing on the tongue and paralysis of the affected side: on sticking it out, the patients tongue will deviate toward the affected side.References
- Biller J, Feinberg WM, Castaldo JE, Whittemore AD, Harbaugh RE, Dempsey RJ, Caplan LR, Kresowik TF, Matchar DB, Toole JF, Easton JD, Adams HP Jr, Brass LM, Hobson RW 2nd, Brott TG, Sternau L. Guidelines for carotid endarterectomy: a statement for healthcare professionals from a Special Writing Group of the Stroke Council, American Heart Association. Circulation 1998;97:501-9. PMID 9490248.
- Golledge J, Mitchell A, Greenhalgh RM, Davies AH. Systematic comparison of the early outcome of angioplasty and endarterectomy for symptomatic carotid artery disease. Stroke 2000;31:1439-43. PMID 10835469. Full text,
External links
- Carotid endarterectomy (Baylor College of Medicine)
surgery (from the Greek χειρουργική meaning "hand work") is the medical specialty that treats diseases or injuries by operative manual and instrumental treatment.
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Carotid arterial stenosis is a narrowing of the lumen of the carotid artery, usually by atheroma (a fatty lump or plaque causingatherosclerosis). Atheroma's may cause transient ischemic attacks (TIAs) and cerebrovascular accidents (CVAs) as it obstructs the bloodstream to the brain.
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In human anatomy, the common carotid artery is an artery that supplies the head and neck with oxygenated blood; it divides in the neck to form the external and internal carotid arteries.
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Atheroma
Classification & external resources
ICD-10 I 70.9
ICD-9 440
DiseasesDB 1039
MeSH C14.907.137.126.307 In pathology, an atheroma
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Classification & external resources
ICD-10 I 70.9
ICD-9 440
DiseasesDB 1039
MeSH C14.907.137.126.307 In pathology, an atheroma
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Transient ischemic attack
Classification & external resources
ICD-10 G 45.9
ICD-9 435.9
DiseasesDB 13253
MedlinePlus 000730
eMedicine emerg/604
MeSH D002546
A transient ischemic attack (TIA
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Classification & external resources
ICD-10 G 45.9
ICD-9 435.9
DiseasesDB 13253
MedlinePlus 000730
eMedicine emerg/604
MeSH D002546
A transient ischemic attack (TIA
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Stroke
Classification & external resources
ICD-10 I 61. -I 64.
ICD-9 435 - 436
OMIM 601367
DiseasesDB 2247
MedlinePlus 000726pi
eMedicine neuro/9 emerg/558 emerg/557 pmr/187
MeSH D020521
Stroke (or
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Classification & external resources
ICD-10 I 61. -I 64.
ICD-9 435 - 436
OMIM 601367
DiseasesDB 2247
MedlinePlus 000726pi
eMedicine neuro/9 emerg/558 emerg/557 pmr/187
MeSH D020521
Stroke (or
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Intervention:
ICD-10 code:
ICD-9 code: 38.1
Other codes: Endarterectomy is a surgical procedure to remove the atheromatous plaque
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ICD-10 code:
ICD-9 code: 38.1
Other codes: Endarterectomy is a surgical procedure to remove the atheromatous plaque
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Arteries are muscular blood vessels that carry blood away from the heart.[1] All arteries, with the exception of the pulmonary and umbilical arteries, carry oxygenated blood.
The circulatory system is extremely important for sustaining life.
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The circulatory system is extremely important for sustaining life.
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Intervention:
ICD-10 code:
ICD-9 code: 00.6
Other codes: Angioplasty is the mechanical widening of a narrowed or totally-obstructed blood vessel. These obstructions are often caused by atherosclerosis.
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ICD-10 code:
ICD-9 code: 00.6
Other codes: Angioplasty is the mechanical widening of a narrowed or totally-obstructed blood vessel. These obstructions are often caused by atherosclerosis.
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stent is a tube that is inserted into a natural conduit of the body to prevent or counteract a disease-induced localized flow constriction.
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Applications
The main purpose of a stent is to counteract significant decreases in vessel or duct diameter by acutely propping open..... Click the link for more information.
A shunt in general is a sort of relief valve, or diverter. See:
In railway operations, "shunting" involves the process of sorting items of rolling stock into complete train sets or
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- shunt (medical)
- shunt (electrical)
In railway operations, "shunting" involves the process of sorting items of rolling stock into complete train sets or
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In animals, the brain or encephalon (Greek for "in the skull"), is the control center of the central nervous system, responsible for behavior. The brain is located in the head, protected by the skull and close to the primary sensory apparatus of vision, hearing,
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Electroencephalography is the neurophysiologic measurement of the electrical activity of the brain by recording from electrodes placed on the scalp or, in special cases, subdurally or in the cerebral cortex.
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Carotid stenting (CAS) is a minimally-invasive surgical procedure available to correct carotid stenosis (narrowing of the carotid artery lumen by atheroma). Carotid stenosis can present with no symptoms (diagnosed incidentally) or through symptoms such as transient ischemic attacks
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Medical ultrasonography (sonography) is an ultrasound-based diagnostic imaging technique used to visualize muscles and internal organs, their size, structures and possible pathologies or lesions.
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The circle of Willis (also called the cerebral arterial circle or arterial circle of Willis) is a circle of arteries that supply blood to the brain. It is named after Thomas Willis (1621-1673), an English physician.
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Bleeding, technically known as hemorrhage (American English) or haemorrhage (British English) is the loss of blood from the circulatory system.[1] Bleeding can occur internally, where blood leaks from blood vessels inside the body or externally, either
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hematoma, or haematoma, is a collection of blood, generally the result of hemorrhage, or, more specifically, internal bleeding. Hematomas exist as bruises (ecchymoses), but can also develop in organs.
It is not to be confused with hemangioma.
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It is not to be confused with hemangioma.
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trachea, or windpipe, is a tube that has an inner diameter of about 20-25 mm and a length of about 10-16cm. It extends from the larynx to the primary (main) bronchi in mammals, and from the pharynx to the syrinx in birds, allowing the passage of air to the lungs.
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The hypoglossal nerve is the twelfth cranial nerve (XII). The nerve arises from the hypoglossal nucleus and emerges from the medulla oblongata in the preolivary sulcus separating the olive and the pyramid. It then passes through the hypoglossal canal.
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