Carotid Endarterectomy (CEA)

Derek Edward Jones, MD
The Operative Review of Surgery. 2023; 1:243-252.

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Table of Contents

Indications
Technique
Shunting and Intraoperative Neuromonitoring
Complications

Mnemonics
References

Indications

Definition

  • Open Surgery to Remove Plaque from the Carotid Artery
  • Goal: Prevent Future Stroke

Indications

Contraindications

  • Absolute Contraindications:
    • Asymptomatic Complete Occlusion – The Only Absolute Contraindication
  • Relative Contraindications:
    • “Hostile Neck” (Prior Neck Radiation, Tracheostomy, or Surgery)
    • Contralateral Vocal Cord Paralysis
    • High Lesions (Above C2 Vertebrae) – Avoid Mandibular Subluxation Required for Open CEA
    • Low Lesions (Below Clavicle)
    • Recurrent Severe Stenosis
    • High Surgical Risk
  • *May Consider Carotid Artery Stenting for Patient with Relative Contraindications Instead

Bilateral Repairs

  • Combined Surgery (Bilateral Repair in Same Surgery) is Generally Contraindicated
  • Generally Perform a Staged Repair if Indicated
    • Repair the Symptomatic Side First
    • If Asymptomatic: Repair the Side with Greatest Stenosis First
    • If Both Sides Equal: Perform the Dominant Side First
  • Evaluate for Vocal Cord Paralysis Prior to Proceeding with the Second Side

Technique

Positioning
  • Neck Extended, Often Using a Bump Under the Shoulders
  • Neck Rotated to the Contralateral Side
  • Arms at the Side
Incision
  • Standard Incision: Longitudinal Along the Medial Border of the Sternocleidomastoid Muscle (SCM)
  • Transverse Incision: 1-2 cm Below the Angle of the Jaw
    • Technically May Be More Difficult
    • Primarily Used for Cosmesis
Procedure
  • Expose the Carotid Sheath
    • Divide Platysma
    • Mobilize Medial Border of SCM
    • *Avoid Injury to External Jugular Vein
    • *Avoid Injury to Greater Auricular Nerve
  • Enter the Carotid Sheath
    • Minimize Carotid Artery Manipulation (Embolization Risk)
    • Dissect Medial Border of the Internal Jugular Vein
      • Divide Facial Vein (Seen Crossing Medially)
    • Retract Internal Jugular Vein Laterally
    • *Identify and Preserve the Vagus Nerve (Generally Posterior Between the IJ and Carotid; May Lie Anterior)
  • Dissect the Carotid Artery
    • Identify Common Carotid Artery (CCA), External Carotid Artery (ECA), and Internal Carotid Artery (ICA)
      • Dissect ICA Past the Area of Stenosis
      • Avoid Injury to the Carotid Body at the Bifurcation
    • Identify Structures
      • Ansa Cervicalis (Medial to CCA)
      • Superior Thyroid Artery (Off Proximal ECA)
      • Hypoglossal Nerve (Superior Extent)
    • Control Inflow and Outflow Circumferentially (Vessel Loops, Rummel Tourniquet, or Vascular Clamps)
    • Superior Thyroid Artery (First Branch of ECA) May Need to Be Controlled or Ligated
  • Clamping: Mn
    • Administer 70-100 U/kg Heparin Prior to Clamping
      • Allow 3 Minutes for Circulation
    • First Clamp ICA (Prevent Embolization to Brain)
      • Ensure Clamping on a Normal Portion of Artery, Distal to Plaque
    • Second Clamp CCA
    • Third Clamp ECA
  • Preform Endarterectomy
    • Consider Shunt Placement – *See Below
  • Close
    • Close Platysma
    • Close Skin
Conventional Endarterectomy
  • Vertical Arteriotomy
    • From CCA into ICA
  • Endarterectomy
    • Begin Proximally in the CCA (Between Media and Adventitia)
      • Remove Intima and Part of Media
    • Continue Distally into the ICA
      • Primary Concern: Ensure a Good Distal End Point
      • Endpoint at Normal Intima with Gradual Tapering
    • Extend into the ECA Orifice with Gradual Tapering
  • Close with a Patch
    • Options: Autologous, PTFE, Dacron, or Bovine
    • Back Bleed Vessels and Irrigate with Heparinized Saline Prior to Final Closure
    • Goal of a Patch: Prevent Narrowing and Restenosis
    • *In General Patch Represents the Standard of Care Although Some Now Suggest Selective Patching if Diameter ≥ 6 mm (Debated) 3
  • Release Clamps Mn
    • First Release ICA Clamp Briefly to Back Bleed then Replace
    • Then Release Clamps on ECA and CCA (Diverting Any Residual Air/Debris to ECA)
    • Finally Remove the ICA Clamp
Eversion Endarterectomy
  • Completely Transect the ICA at the Bifurcation
  • ICA Adventitia is Then Everted Circumferentially (“Circumcised”) Off the Carotid Plaque
  • Plaque is Then Removed from the CCA
  • ICA is then Re-Anastomosed to the Bifurcation by Simple End-to-End Anastomosis
    • No Patch Required
  • *Similar Results and Complications Between Conventional and Eversion Techniques 4

CEA Incisions; Standard (Solid Line) and Transverse (Dashed Line) 1

Facial Vein 2

CEA Clamping (I.C.E.) 5

Conventional Endarterectomy 5

Patch Angioplasty 5

Eversion Arterial Transection 5

Eversion Endarterectomy 5

Eversion Closure 5

Shunting and Intraoperative Neuromonitoring

Shunting Definition

  • Small Plastic Tube Used to Shunt Blood from the Common Carotid into the Internal Carotid Artery During Dissection
  • Goal: Maintain Cerebral Perfusion
  • Multiple Types of Commercially Available Shunts Exist

“Selective” Shunting Indications

  • Any Evidence of Cerebral Ischemia
  • Awake Patients Performed Under Local Anesthesia:
    • Agitation
    • Confusion
    • Slurred Speech
    • Weakness
  • EEG Delta Waves or Disorganized Rhythms
  • Carotid Stump Pressures (Mean Systolic Pressure < 50 mmHg) 6,7

Outcomes

  • Routine Shunting (Compared to No Shunting): 8
    • Lower Risk of Perioperative Stroke
    • Lower Risk of Ipsilateral Stroke at 30 Days
    • Lower Risk of Stroke-Related Death at 30 Days
  • Selective Shunting (Compared to Routine Shunting): 9,10
    • No Significant Difference
    • Mostly Based on Surgeon Preference

Shunting Complications

  • Plaque Dislodgement
  • Intimal Flap/Dissection
  • Air Embolism

Technique

  • First Place Distal Segment into the Internal Carotid Artery
    • Clamp to Prevent Blood Flow Around the Shunt
    • Back Bleed to Clear Air and Debris
  • Then Place Proximal Segment into the Common Carotid Artery
  • Proceed with Endarterectomy

Complications

Mortality

  • 30-Day All-Cause Mortality: 0.93% 11
  • 40x Increased Risk After a Stroke 11

Perioperative Stroke

  • Incidence: 2.15% 11
  • Causes: 12,13
    • Technical Causes:
      • Residual Intimal Flap
      • Thrombosis
    • Plaque Emboli
    • Platelet Aggregation
    • Inadequate Cerebral Protection
    • Improper Flushing
    • Relative Hypotension
  • Mostly Reversible if Flow is Restored within 1-2 Hours
  • Management: Immediate Reexploration in the OR vs Duplex Ultrasound (If Rapidly Available)
    • Immediate Reexploration Often Recommended for a Presumed Intimal Flap or Thrombosis
    • Other Evaluations if Duplex Negative:
      • CT Head (Rule Out Hemorrhage)
      • CTA Head and Neck
      • Arteriography and Carotid Artery Stenting 14

Restenosis

  • Risk: 2-10% 15-18
    • *Historically Reported as High as 20% 19
  • Causes: 20
    • Immediate (< 4 Weeks): Technical Error
    • Early (< 2 Years): Myointimal Hyperplasia
    • Late (> 2 Years): Recurrent Atherosclerosis
  • Treatment: 21
    • Asymptomatic: Conservative Management vs Reintervention (Controversial)
    • Symptomatic: Reintervention (Carotid Artery Stent vs Repeat CEA)

Myocardial Infarction (MI)

  • Incidence: 0.87% 22
  • Causes 25-50% of Perioperative Deaths

Cranial Nerve Injury (CNI) 23,34

  • General Considerations:
    • Most Are Transient and Resolve After 3-4 Weeks
    • Overall Risk of Injury: 5-20%
    • Risk of Permanent Injury: 0-1%
  • Vagus Nerve Injury (Recurrent Laryngeal Nerve) (1-4%)
    • The Most Feared/Dangerous Nerve Injury
    • Location: Within the Carotid Sheath
    • Presentation: Hoarseness (Vocal Cord Paralysis) and Dysphagia/Aspiration
    • Typically Injured During Vascular Clamping
  • Hypoglossal Nerve Injury (3-4%)
    • Location: Just Above the Carotid Bifurcation
    • Presentation: Speech and Mastication Deficit
    • Tongue Deviates to the Ipsilateral Side of Injury
  • Facial Nerve Injury (Marginal Mandibular Branch) (1-2%)
    • Presentation: Smiling Deficit (Corner of Mouth Retraction)
    • Typically Injured from Excessive Superior Retraction
  • Glossopharyngeal Nerve Injury (0.2-0.5%)
    • Presentation: Swallowing Difficulty
    • Rare; Most Common with High Dissections
  • Ansa Cervicalis Injury
    • Presentation: Strap Muscle Deficits
  • Greater Auricular Nerve Injury
    • Presentation: Earlobe Numbness

Cerebral Hyperperfusion Syndrome (CHS)

  • Definition: Impaired Autoregulation of Cerebral Perfusion After Chronic Hypoperfusion
    • Increased Perfusion Causes Dilation of Vessels that are Unable to Appropriately Vasoconstrict – Result in Edema and Hemorrhage
  • Risk: 0.75-3% 25
  • Risk Factors: 25
    • Preoperative High-Grade Stenosis (> 80%)
    • Postoperative Hypertension
    • Recent Contralateral CEA
    • Contralateral Carotid Occlusion
    • Intraoperative Ischemia
    • Increased Peak Flow Velocity
    • Low Stump Pressures (< 40 mmHg)
  • Presentation: 26
    • Hypertension
    • Frontal Headache (Ipsilateral or Diffuse)
    • Stroke and Seizure
  • High Mortality (36-63%) 25
    • Significant Morbidity (80%) Among Survivors 25
  • Evaluate with Head CT or MRI for Potential Intracerebral Hemorrhage
  • Management: Antihypertensives and Anti-Seizure Medications
    • Strict Blood Pressure Control (< 140/90 mmHg) May Be Able to Prevent 27

Cervical Hematoma

  • Incidence: 1-5% 28
  • Risk Factors:
    • Antiplatelet Therapy
    • Non-Reversal of Heparin
  • Most Often from Diffuse Oozing Rather than a Single Bleeding Site
  • Creates a Risk Tracheal Compression and Airway Loss
  • Treatment: Emergent Intubation and Immediate Reexploration/Evacuation in the OR
    • Emergent Opening of the Incision with Hematoma Evacuation (As in Thyroidectomy) May Be Necessary if Airway Collapsing with Inability to Intubate
    • *Note that There is Possibility of Graft Blowout that Requires Repair in the OR and Opening at Bedside Should Be Avoided Unless Emergently Necessary

Surgical Site Infection (SSI) 29-31

  • Depth:
    • Superficial SSI – Most Common
    • Deep SSI Involving the Patch – Rare
  • Presentation: Pain, Swelling, Fever, Erythema, and Drainage
  • Management: Antibiotics and Drainage of Any Fluid Collection/Abscess
    • If Fails, May Require Surgical Revision with Patch Excision and Carotid Ligation, Reconstruction, or Bypass

Post-Endarterectomy Pseudoaneurysm (PEPA) 32-34

  • Rare (< 1%)
  • Risk Factors:
    • Suture Line Disruption
    • Arterial Wall/Patch Degeneration
    • Surgical Site Infection
    • Clamp/Shunt-Induced Damage
  • Complications: Rupture, Thrombus, Embolism, or Airway Compression
  • Most Often Presents as a Pulsatile Mass
  • Evaluate with Duplex US
    • Other Options: CTA, MRI, or Angiography
  • Treatment: Urgent Surgical Repair (Open or Endovascular)

Carotid Body Injury

  • Can Result in Significant Hypertension
  • Generally Transient
  • Managed with Aggressive Blood Pressure Control to Prevent Cerebral Hyperperfusion Syndrome

Mnemonics

Clamping Order for CEA

  • “I-C-E”
    • ICA (First)
    • CCA (Second)
    • ECA (Last)
  • Unclamp in the Opposite Order (E-C-I)

References

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