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Management of Concomitant Carotid and Coronary Arterial Disease

The management of patients with coexistent carotid and coronary artery disease (CAD) depends upon the circumstances of clinical presentation. Most surgeons would agree that symptomatic carotid stenosis requires prompt, if not urgent, surgical therapy based on presentation. In such patients, concurrent CAD should be managed with maximal medical therapy in the perioperative setting. A more controversial issue is the management of patients who require coronary artery…

Treatment of Recurrent Stenosis After Previous Carotid Endarterectomy

Carotid endarterectomy (CEA) is the gold standard in the treatment of carotid occlusive disease and prevention of stroke. However, the benefit of carotid revascularization is hampered by restenosis, which is associated with a modestly increased risk for stroke. Symptomatic recurrent stenosis has been reported to range between 0.6% and 3.6%, and asymptomatic restenosis, based on noninvasive studies, ranges from 8.8% to 19%. A systematic review in…

Pathology of Carotid Artery Restenosis

Restenosis at the site of previous atherosclerotic plaque removal or dilatation commonly accompanies mechanical methods to reopen an artery. This often follows balloon angioplasty, atherectomy, endarterectomy, or arterial stenting. In arterial stenting, tissue grows inside the stent, causing a luminal stenosis. In general, the pathologic basis of restenosis appears to be a substantial increase in intimal volume of the affected artery with secondary luminal narrowing. In…

Relevance of External Carotid Artery Disease in Internal Carotid Artery Occlusion

Internal carotid artery (ICA) occlusion has long been thought to carry a poor prognosis despite what is often an asymptomatic presentation. However, increasing recognition of segmentation based on cerebrovascular imaging and/or perfusion monitoring techniques, clinical status of initial presentations, and associated extracranial and intracranial vascular disease, has indicated a heterogeneous population that must be approached thoughtfully to understand the prognosis and determine the optimal treatment strategy.…

Blood Pressure Instability After Carotid Endarterectomy

Sudden fluctuations in heart rate and blood pressure are common among patients undergoing a wide variety of surgical procedures. Although the etiology of hemodynamic instability is multifactorial, this phenomenon is most commonly encountered among patients with preexisting cardiovascular disease and/or those who require vasoactive drugs in the intraoperative and immediate postoperative period. Hemodynamic lability is especially prevalent among patients undergoing cardiovascular procedures, and it is a…

Carotid Occlusion and Near-Carotid Occlusion of the Extracranial Internal Carotid Artery

A diagnosis of an occluded or nearly occluded carotid artery is anxiety provoking for the patient. In these cases, referring physicians often request urgent if not emergent vascular consultation. Because large randomized trials regarding these conditions do not exist, best practices for optimal results require careful history taking, physical examination, appropriate imaging, and careful patient selection. The vascular specialist must have a thorough understanding of the…

Carotid Endarterectomy or Stenting for Evolving Stroke Secondary to Carotid Artery Atherosclerosis

Stroke is the third leading cause of death and the most common cause of long-term neurologic disability worldwide. Each year, 795,000 Americans suffer a stroke, of which 80% are ischemic. Carotid atherosclerotic disease is implicated in 15% to 30% of all ischemic strokes. For decades, carotid endarterectomy (CEA) has been the standard treatment for carotid artery atherosclerosis, but carotid artery stenting (CAS) has emerged as a…

Early Postoperative Recognition and Management of Acute Stroke After Carotid Endarterectomy

Stroke complicating carotid endarterectomy (CEA) is broadly classified into intraoperative or postoperative. Such a classification has implications for the likely etiology and type of stroke and indication for exploration or neurorescue maneuvers; it also affects prognosis. An intraoperative stroke is defined as a major neurologic deficit recognized at the conclusion of surgery, whereas an early postoperative stroke is defined as a major neurologic deficit that develops…

Intraoperative Recognition and Treatment of Cerebral Ischemia During Carotid Endarterectomy

Neurologic complications during the performance of carotid endarterectomy (CEA) are most commonly caused by embolization from the area of the carotid bifurcation or a result of hypoperfusion from inadequate collateral blood flow during carotid clamping. The recognition of intraoperative cerebral ischemia during surgery depends on the type of anesthetic protocol used: regional anesthesia with the patient awake or general anesthesia with or without cerebral perfusion monitoring.…

Intraoperative Assessment of the Technical Adequacy of Carotid Endarterectomy

Improving the results of carotid endarterectomy (CEA) through technical excellence will likely further establish the known effectiveness of the procedure. Technical errors, which can lead to perioperative stroke, include arterial strictures, intraluminal thrombi, intimal flaps, and arterial kinks. These defects can be diagnosed by the proper use of intraoperative testing. It is logical to assume that correction of these defects before completing the procedure should decrease…

Role of Shunting During Carotid Endarterectomy

Temporary clamping of the internal carotid during carotid endarterectomy (CEA) interrupts antegrade blood flow to the brain in the distribution of the ipsilateral middle and anterior cerebral artery. The consequence of clamping the internal carotid artery is of critical importance to the patient and has been the subject of debate for more than 50 years. In a 1998 editorial, Denton Cooley wrote, “No consensus concerning the…

Management of the Infected Carotid Artery Patch

It is likely that everyone performing carotid endarterectomy (CEA) is aware of prosthetic patch infection, but only 123 cases have been reported in the world literature from 29 published series (18 of which reported a single case). Accordingly, because surgeons only tend to publish good outcomes, it is likely that the procedural risks and longer-term rates of reinfection (or other adverse outcomes) may be considerably underestimated.…

Patch Graft Closure with Carotid Endarterectomy

Stroke is the third leading cause of death in the United States. Approximately 15% to 52% of all ischemic strokes are caused by extracranial cerebrovascular atherosclerotic lesions. It has also been estimated that 103,000 carotid endarterectomies (CEAs) were done in the United States in 2005. Few procedures have been scrutinized as thoroughly as CEA during the last 2 decades. The Society of Vascular Surgery, in a…

Technical Aspects of Eversion Carotid Endarterectomy for Atherosclerotic Disease

All methods of arterial closure following a standard carotid endarterectomy (CEA) are associated with appreciable rates of persistent or recurrent internal carotid artery (ICA) stenoses, of which some are related to technical issues in closing the artery. Eversion endarterectomy of the ICA is an alternative technique that had its origins in the United States and recent resurgence in Europe. The eversion technique, as currently conceived, involves…

Technical Aspects of Conventional Carotid Endarterectomy for Atherosclerotic Disease

Carotid endarterectomy (CEA) is a conceptually simple but technically unforgiving surgical procedure. Although other factors like patient selection and preoperative antiplatelet therapy also play an important role, a good clinical outcome after CEA probably is related most directly to the technical perfection of the operation itself. Provided they are accurate, data from the Nationwide Inpatient Sample suggest that as many as 90% of the CEAs in…

Treatment of Recurrent Carotid Artery Stenosis After Percutaneous Angioplasty and Stenting

Carotid endarterectomy (CEA) has been proved effective at reducing the risk of stroke in large-scale landmark clinical trials. These randomized trials have established indications for CEA in selected patients with symptomatic stenosis of 50% or more and asymptomatic stenosis of 60% or more. The emergence of carotid artery stenting (CAS) has been accompanied by much deliberation. Carotid artery stenting has become an alternative to reoperation in…

Cerebral Hyperperfusion Syndrome After Carotid Endarterectomy and Carotid Stenting

Cerebral hyperperfusion syndrome (CHS) and intracerebral hemorrhage are perhaps the most feared complications of carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS). Although relatively uncommon, such complications can have devastating and often fatal sequelae and remain a significant cause of neurologic morbidity after carotid interventions. Intracerebral hemorrhage (ICH) after cerebral revascularization was recognized as early as 1964 by Wylie and colleagues and was found to…