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Eversion endarterectomy of the internal carotid artery (ICA)

Preoperative diagnostics and management

  • Clinical assessment: age, risk factors, cardiac or any other co-morbidities, life expectancy, cardiological assessment if coronary heart disease is suspected
  • Neurological examination a couple of days preoperatively
  • Vascular imaging: Duplex ultrasound of the carotid bifurcation and the vertebral arteries, MR-Angiography or CT-Angiography of the extra- and intracranial arteries (status of the circle of Willis)
  • Brain imaging by MRT or CCT: silent brain infarcts or any other abnormalities?
  • Preoperative medication: Aspirin 100mg per day, lipid-lowering medication (preferrably statins). Never stop antithrombotic and lipid-lowering medication preoperatively!
  • CEA should also be considered in patients under double platelet inhibition (for cardiac reasons), especially in patients with a sympomatic carotid stenosis
  • In patients with a symptomatic carotid stenosis CEA should be performed as soon as possible after the neurological index event. A close cooperation with the stroke physicians is needed to prevent recurrent cerebral ischaemia!

Procedure

  1. Preparation of the patient
  • Anesthesiological management, including locoregiona anesthesia (1st choice) or general anesthesia
  • Looking for a skin fold in the neck (dotted line)
  • Duplex ultrasound and marking the carotid bifurcation on the skin
  • Marking the other anatomic landmarks: eye lobe, jugulum and mandible
  • Positioning of the patient (beach chair)
  1. Skin incision and exposure of the carotid bifurcation
  • Skin incision (ideally in a skin fold), the incision should be extendable towards the jugulum and behind the eye lobe
  • Only bipolar coagulation!
  • Dissection of the platysma and positioning of the first retractor (lower wound area)
  • Identifying the common carotid artery (CCA) and the carotid bifurcation, 3.000 IU of Heparin i.v.
  • Slings around the CCA, the superior thyroid artery and the external carotid artery (ECA, cave: hypoglossal and vagal nerves, ansa cervicalis can be transsected, when the hypoglossal nerve has been identified)
  • Identifying the ventral wall of the jugular vein and dissection of the facial vein (Polypropelene 5/0)
  • Second wound retractor in the upper angle (cave: compression of facial nerve branches against the mandible)
  • No sling around the internal carotid artery (ICA), no extensive preparation of the carotid bulb or ICA before clamping (“no-touch-technique, especially important in patients with a symptomatic stenosis)
  • Elevating the systolic blood pressure to 160mmHg and asking the awake patient to move the contralateral hand
  • Gentle clamping of the CCA (Dardik clamp), the ECA and the thyroid artery (Yasargil clamps both)
  • Incison of the carotid bulb and assessing the backflow + the neurological status of the patient
  • Good/sufficient backflow in combination with no neurological problems: proceed with eversion CEA, otherwise consider to proceed with longitudinal incison of the ICA and CCA plus shunting immediately
  1. Eversion endarterectomy of the internal carotid artery (ICA)
  • Excision/transsection of the ICA, clamping of the ICA above the plaque (Yasargil clamp)
  • Eversion endarterectomy of the ICA with visual control of the distal edge of the plaque (loupe magnification, irrigation with saline), VERY IMPORTANT
  • Gentle dilatation of the distal edge by use of vessel bougies (4-5mm) under backflow
  • Control of the backflow (pulsatility, colour), in rare situations patients become symptomatic under ICA backflow, the ICA has to be re-clamped immediately)
  • Optional: shunt insertion in the CCA (first) and the ICA under continous backflow (cave: air bubbles and distal dissection by the shunt!)
  • Two stay sutures in the ICA, one stay suture in the CCA
  • Optional: local endarterectomy of the distal CCA
  1. Reconstruction of the carotid bifurcation
  • Two stay sutures in the ICA, one stay suture in the CCA
  • Reinsertion of the ICA, running suture 5/0 or 6/0, starting in the upper angle
  • Suturing starts on the opposite side, stitch direction: ICA outside, CCA inside, stitching direction towards the surgeon, running suture (parachute technique), no change of the needle necessary
  • Shunt removal (optional) and flushing of the CCA (first), the ICA (backflow) and the ECA (backflow)
  • Completion of the suture line while ICA and CCA are clamped and ECA is backbleeding (will remove air bubbles)
  • Systolic blood presure can be normalized again and must not exceed 140mmHg for the next days
  1. Assessment/intraoperative control of the technical result: angiography and/or b-mode/duplex ultrasound
  • Rationale: looking for residual stenosis, local dissection, thrombi etc
  • Completion angiography: retrograd puncture of the CCA below the bifurcation in a plaque free area
  • Aspiration and connection with an extension line, local heparinization
  • Positioning of the C-arm and gentle infusion of the contrast solution (6-8ml contrast + 2-4ml saline)
  • First series, while the ECA is clamped again, looking especially at the distal edge and a patent intracranial ICA, carotid-T, and middle/anterior cerebral artery (ACA sometimes not visible due to an ongoing collateral blood flow from the opposite side)
  • Second series of the carotid bifurcation while all arteries are declamped , optional: second projection
  • B-mode/Duplex ultrasound: small probes are necessary. Starting at the CCA (oblique and longitudinal) and going up beyond the endarterectomised segment of the ICA
  • Optional: flow measurements of CCA, ICA and ECA (physiological flow distribution: 100% – 60-70% -30-40%)

Postoperative management and follow-up

  • Strict blood pressure control postoperatively with measurements at least every 4 hours for 24 hours, a maximum blood pressure of 140/90 mmHg is acceptable
  • Postoperative monitoring for at least 2 hours in a wake-up room (close to the OR) including neurological supervision, blood pressure control, airway control and control of the wound (bleeding, swelling etc)
  • Ongoing blood pressure control on the regular ward for at least 24 hrs (every 4 hrs)
  • If headache occurs, lower the blood pressure immediately. If headache persists, a CCT (or MRT) is needed to exclude cerebral bleeding
  • The wound drainage can usually be removed after 24 hours
  • Regular neurological examination 24-48 hours postoperatively
  • Longterm medication with Aspirin and lipid-lowering agents, preferrably statins
  • Clinical and sonographic follow-up in the outpatient department after 4 weeks, one year and five years
  • In patients with suspected recurrent stenosis and/or >50% contralateral carotid stenosis, control examinations should be performed earlier

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