Vascular Conference

July 25, 2017

Imad Mokalled PGY-3
00372368
Case Presentation
• 77 year old female patient
• July 10: presented to ER with acute onset of headache, confusion, and
dysarthia
• MRA was done to rule out stroke
• MRA:  Watershed Acute infarct in the left parietal occipital region with
haemorrhagic transformation.
• Pre-occlusive disease at the takeoff of the left internal carotid artery
with around the 80-90% luminal narrowing.
•  Thrombosis of the left vertebral artery with reconstitution of flow in
its V4 segment via reflux flow from the basilar trunk.
Case Presentation
• Patient was admitted under care of neurology for 2 days
• Started on aspirin
• Symptoms improved in terms of orientation and speech
• Duplex done on July 11
Case Presentation
Case Presentation
• Patient was scheduled for left carotid endarterectomy
• Admitted to our service on July 20
• Plavix was added to aspirin
• PMHx: HTN type 1 DM disc disease
• PSHx: laminectomy
• Allergies: none
• Meds: cipralex magne B6 concor am esidrex pariet solpadeine euro D
Orocal D3 Amlor atacand Aspirin
Case Presentation
• Social Hx: heavy smoker 50 pack year non alcoholic
• Family Hx: positive for DM
Case Presentation
Physical Exam:
VS: 36.6 152/57 64 18 SatO2: 98%
• GA: NAD alert oriented*3
• Left Carotid bruit
• Radial Pulses: 2+ bilaterally
• Normal motor power and sensation in 4 extremities
• No dysarthia
• Cranial Nerves: 3-12 grossly normal
Case Presentation
• CBC: 6900 12 36 358K
• INR 1
• Cr 0.8
Case Presentation
• Ct angio was done
• Ct angio: There is severe, approximately 90%, short segment narrowing
at the takeoff of the left ICA by mixed calcified and soft tissue plaque.
There is also a mixed soft tissue/calcified atherosclerotic plaque and
the takeoff of the right ICA with approximately 50% stenosis.
No significant obstructive pathology or aneurysm formation in the
intracranial circulation.
There are non-obstructive calcified plaques involving the cavernous
ICAs bilaterally and mixed soft tissue and calcified plaques in both
common carotid arteries, more so on the left.
• Re-demonstration of the subacute stroke in the left parietal lobe and
small vessel ischaemic changes
Case Presentation
• OR (July 21)
Left carotid endarterectomy with right greater saphenous vein patch
Case Presentation
• Postop: SBP: 120-130
• Neurologically intact
• POD1: aspirin and plavix resumed
Patient tolerated regular diet
Foley catheter removed
• POD2: neck and thigh drains were removed
• POD3: patient was discharged home
Case Presentation
Carotid Endarterecotmy
Definitions and Indications
• Definition: CEA is the removal of the diseased intima and media of the
carotid artery.

• Aim: to prevent the adverse sequelae secondary to atherosclerotic

disease i.e ischemic stroke.

• Definition of symptomatic vs non-symptomatic:

• Sxic: either TIAs or minor stroke defined as a focal neurologic defect affecting
one side of the body, speech, or vision.
• Asxic: pts have narrowing but have not experienced a TIA or a stroke.
Definitions and indications (Cont’d):
• NASCET trial (1999): The North American Symptomatic Carotid
Endarterectomy Trial
• Clinical question: In patients with symptomatic stenosis, does CEA reduce
risk of death or stroke?
• Prior studies had demonstrated the benefit of carotid endarterectomy (CEA)
in patients with severe carotid stenosis
• NASCET was the first large, well-designed trial to study CEA in patients with
low-moderate (<50%), high-moderate (50-69%), and severe (≥70%) stenosis.
• Those with symptomatic 50-69% stenosis had a 29% reduction in the 5-year
risk of death or stroke, while those with <50% stenosis had no such benefit.

Barnett HJ, et al. "Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis". 
The New England Journal of Medicine. 1998. 339(20):1415-25.
 Definitions and indications (Cont’d):
• Those with ≥70% stenosis received such a dramatic benefit that this
study arm was prematurely stopped and all patients with severe
stenosis were subsequently referred for CEA.
Comparisons are CEA vs. medical management
Primary Outcomes:

Ipsilateral stroke at 5 years

With 50-69% stenosis
15.7% vs. 22.2% (RR 0.71; 95% CI 0.48-0.93; P=0.045), NNT=15
With <50% stenosis
14.9% vs. 18.7% (P=0.16)

Secondary Outcomes
Death or stroke at 30 days
With 50-69% stenosis
33.2% vs. 43.3% (RR 0.77; P=0.005), NNT 10
With <50% stenosis
36.2% vs. 37% (RR 0.98; P=0.97)
Definitions and indications (Cont’d):
• Bottom line: CEA reduces the 5-year risk of death or stroke by 29%
among patients with symptomatic high-moderate (50-69%) carotid
stenosis.
Definitions and indications (Cont’d):
• ECST trial (1998): European Carotid Surgery Trial 
• CEA significantly reduced the rate of major stroke or death compared
to usual medical care (14.9% vs. 26.5%; NNT=9) for >80% stenosis
• CEA did not appear to benefit patients with <80% stenosis.
• The ECST criteria have been found to overestimate stenosis severity
relative to NASCET criteria
 Definitions and indications (Cont’d):
AHA/ASA Guidelines for Symptomatic CEA (2014, adapted)

•For patients with a TIA or ischemic stroke within the past 6 months and ipsilateral severe (70-99%)
carotid artery stenosis as documented by noninvasive imaging, CEA is recommended if the perioperative
morbidity and mortality risk is estimated to be <6% (Class 1A)

•For patients with recent TIA or stroke and ipsilateral moderate (50-69%) carotid stenosis as documented
by catheter-based imaging or noninvasive imaging with corroboration (MRA or CTA), CEA is recommended
depending on patient-specific factors such as age, sex, and comorbidities if perioperative morbidity and
mortality risk is estimated to be <6% (Class 1B)

•When the degree of stenosis is <50%, CEA and CAS are not recommended (Class IIIA)
Definitions and indications (Cont’d):
• ACAS (1995): Asymptomatic Carotid Atherosclerosis Study
• 1st study examining carotid endarterectomy in asymptomatic patients
with carotid narrowing 60-99%
• Showed that over 5 years the risk of stroke or stroke and death was
reduced from 11% to 5.1%. 
• There was no evidence of any more or less benefit as the narrowing
approached 99%.

Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid
Atherosclerosis Study. JAMA. 1995. 10;273(18):1421–8.
 Definitions and indications (Cont’d):
• ACST: Asymptomatic Carotid Surgery Trial
• Comparing patients without symptoms allocated immediate carotid
endarterectomy (for 60-99% stenosis) versus all those allocated non-
surgical management the net 5 year risk was 6.4% (with surgery)
versus 11.8% (only medical treatment). 
• In men under the age of 75 years the benefit of surgery was clear cut
(8.2% decrease in 5 year risk of stroke with surgery). 
• Follow up studies indicate there is a clear benefit for women which
appears close to or equivalent to the benefits for men.

Halliday A, et al. "10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1):
a multicentre randomised trial". The Lancet. 2010. 376(9746):1074-1084.
Definitions and indications (Cont’d):
• Patients with asymptomatic carotid atherosclerosis should receive
intensive medical therapy:
• statin therapy
• antiplatelet therapy
• blood pressure control
• and lifestyle modification consisting of smoking cessation, limited
alcohol consumption, weight control, regular aerobic physical activity,
and a Mediterranean diet
Definitions and indications (Cont’d):
• For medically stable patients who have a life expectancy of at least
five years and a high grade (≥80 percent) asymptomatic carotid
stenosis at baseline or have progression to ≥80 percent stenosis
despite intensive medical therapy while under observation, carotid
endarterectomy (CEA) is recommended, provided the combined
perioperative risk of stroke and death is less than 3 percent for the
surgeon and center (grade 2b)

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of

patients with extracranial carotid and vertebral artery disease.
Definitions and indications (Cont’d):
• Repair the tightest side first

• Repair the dominant side first if the patient has equally tight carotid
stenosis bilaterally

• Use a shunt during CEA for stump pressures < 50 or if contralateral side is
tight, some always use a shunt.
• For maximum benefit patients should be operated on soon after a TIA or
stroke, preferably within the first 2 weeks as recommended by the
National Institute of Health and Clinical Excellence (NICE) guidelines.
Definitions and indications (Cont’d):
• The Carotid Revascularization Endarterectomy versus Stenting Trial
(CREST) funded by the National Institute of Health (NIH) reported that
the results of stents and endarterectomy were comparable.

• CREST: Stenting versus Endarterectomy for Treatment of Carotid-

Artery Stenosis (2010)
• Clinical question: In patients with carotid artery stenosis, how does
carotid artery stenting compare with carotid endarterectomy in terms
of stroke, MI, and death?
 Definitions and indications (Cont’d):
• enrolled 2,502 patients with carotid artery stenosis and randomized
patients to either stenting or CEA.
• demonstrated that stenting and CEA were similar in regards to the
primary outcome of periprocedural stroke, MI, death, or ipsilateral
stroke within 4 years.
• Secondary analyses revealed more periprocedural strokes with
stenting (4.1% vs. 2.3%) but fewer periprocedural MIs (1.1% vs. 2.3%).

Brott TG, et al. "Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis". The New England Journal of
Medicine. 2010. 363(1):11-23.
Definitions and indications (Cont’d):
• Endarterectomy remains the preferred method of revascularization
for most patients with symptomatic carotid atherosclerosis who have
standard surgical risk.
• CAS and CEA provide similar long-term outcomes for patients with
asymptomatic and symptomatic carotid occlusive disease, while the
periprocedural risk of stroke and death may be higher with CAS.
Definitions and indications (Cont’d):
• The 2011 AHA/ACCF guidelines recommend stenting as a reasonable
alternative to CEA among symptomatic patients with stenosis >70%
and low risk of periprocedural complications (class I)
• CEA might be preferred among older patients or those with anatomy
not amenable to stenting (class IIa).
• Prophylactic stenting for select asymptomatic patients with stenosis
>70% by Doppler may be reasonable (class IIb).
High risk criteria for CEA include the following:

• Age ≥80 years.

• Class III/IV congestive heart failure.
• Class III/IV angina pectoris.
• Left main or multi vessel coronary artery disease.
• Need for open heart surgery within 30 days.
• Left ventricular ejection fraction of ≤30%.
• Recent (≤30-day) heart attack.
• Severe lung disease or COPD.
• Severe renal disease.
• High cervical (C2) or intrathoracic lesion.
• Prior radical neck surgery or radiation therapy.
• Contralateral carotid artery occlusion.
• Prior ipsilateral CEA.
• Contralateral laryngeal nerve injury.
• Tracheostomy.
Surgical Details:
 The incision is made along the anterior border of
the sternocleidomastoid muscle.

 The platysma is incised

 Facial Nerve (2.2%) marginal mandibular nerve

 drooping at corner of the mouth, drooling

 GAN: (C2-C3), sensory innervation for the skin

over parotid gland and mastoid process, and
both surfaces of the outer ear.
 As the hypoglossal nerve is encountered it must be
identified and preserved. Risk of injury: 3.7% 
tongue deviation to the side of injury.

 Common carotid artery, vagus nerve and internal

jugular vein have common sheath, which has to be
opened prior to artery dissection. The IJV is lateral
to the artery, and Vagus nerve in between and
posteriorly to both.

 Injury to the vagus nerve (2.5%) Vocal cord

paralysis usually results in hoarseness, impaired
phonation, and an ineffective cough

 Tissue in this area should be manipulated as little

as possible to prevent separation of the
atherosclerotic plague inside the vessel.
 The dissection of the external carotid artery and
its first branch the superior thyroid artery are
performed next, subsequently the other
branches of the ECA, the lingual, the external
maxillary or the facial… are dissected as well.

 The dissection of the internal carotid artery is

completed last.

 Special attention must be paid to another nerve

positioned in this area, the carotid body (or
sinus), which regulates arterial blood pressure.
• Other Nerves
• superior laryngeal nerve: voice
fatigue or alteration in sound
quality

• spinal accessory nerve: shoulder

drop

• glossopharyngeal nerve:
impairment of swallowing and
recurrent aspiration

• sympathetic chain: Horner’s

syndrome
 The vascular clamps are applied to the common
carotid artery and internal carotid artery.

 The ECA and superior thyroid artery are

controlled by gentle traction on the vessel loops.

 A longitudinal incision is then made through the

adventitia on the anterolateral surface of the
carotid artery. The length of this incision is
extended inferiorly into the common carotid
artery below any obvious localized plaque.
• Temporary bypass shunt is inserted.

• Shunt first must be inserted into the

internal carotid artery to ensure
backflow.

• It is very important to have air and

debris cleared by the backflow of the
blood from the internal carotid artery
before gently inserting the shunt into
common carotid artery

• The shunt bypass is now in place,

providing circulation to the internal
carotid artery and to the cerebral
circulation
• Using a small blunt dissector, the plaque is mobilized
from the adventitia.
• The vessel wall is then
carefully inspected, and any
loose strips of atheroma that
remain are carefully peeled
away.

• The internal carotid artery is

closely inspected to ensure
that there is no loose flap
superiorly.
Complications:
• Perioperative or immediate complications
• central neurologic
• local (neck)
• cranial nerve injury
• hemorrhage
• Systemic
• alteration in blood pressure control
• myocardial infarction (MI)
• Late (after 30-day) complications
• recurrent carotid stenosis
• Suture line or patch disruption associated with infection
Complications (Cont’d):
Central Neurologic Complications or Death
• Perioperative Stroke or Death
• endarterectomy site thrombosis and/or embolism from the
endarterectomy site
• ischemia at the time of carotid clamping
• embolism during dissection
• embolism from remote sites
• Hyperperfusion/Cerebral Hemorrhage

• disturbed cerebral autoregulation that develops in the territory of a

carotid stenosis.

• unilateral headache, seizure activity, and cerebral hemorrhage

• 2 to 7 days

• Hyperperfusion: 2% to 3%

• Cerebral haemorrhage: 0.2% to 0.8%

Hyperperfusion/Cerebral
Hemorrhage
• Risk factors:
• very high-grade carotid stenoses
• contralateral occlusion
• Uncontrolled hypertension
• Diagnosis:
• MRI/MRA
• CT
• Treatment:
• seizure precautions and aggressive blood pressure management
• seizure medication prophylaxis
• Stop antiplat.
Thank you