CareWorks Health Services
Moulton Parkway STE 103C
Laguna Hills, CA 92653
artery is the large vertical artery in red. The
blood supply to the common carotid artery starts at
the arch of the aorta
(left) or the subclavian
artery (right). The common carotid artery divides
into the internal carotid artery and the external
carotid artery. Plaque often builds up at that division,
and a carotid endarterectomy cuts open the artery
and removes the plaque.
endarterectomy (CEA) is a surgical
procedure used to reduce the risk of stroke,
by correcting stenosis
(narrowing) in the common
carotid artery or internal carotid artery. Endarterectomy
is the removal of material on the inside (end-) of
to form in the carotid arteries, usually at the fork where
the common carotid artery divides into the internal and
external carotid artery. The plaque can build up in the
inner surface of the artery (lumen),
and narrow or constrict the artery. Pieces of the plaque,
can break off (i.e. embolize) and travel up the internal
carotid artery to the brain, where it blocks circulation,
and can cause death of the brain tissue.
the plaque causes temporary symptoms first, known as TIAs,
where transient ischemia occurs in the brain, spinal cord,
or retina without causing an infarction.
Symptomatic stenosis has a high risk of stroke within the
next 2 days. National
Institute for Health and Clinical Excellence (NICE)
guidelines recommend that patients with moderate to severe
(50–99% blockage) stenosis, and symptoms, should have "urgent"
endarterectomy within 2 weeks.
the plaque doesn't cause symptoms, patients are still at
higher risk of stroke than the general population, but not
as high as patients with symptomatic stenosis. The incidence
of stroke, including fatal stroke, is 1–2% per year. The
surgical mortality of endarterectomy ranges from 1–2% to
as much as 10%. Two large randomized clinical trials have
demonstrated that carotid surgery done with a 30-day stroke
and death risk of 3% or less will benefit asymptomatic patients
with greater than or equal to 60% stenosis who are expected
to live at least 5 years after surgery.
Surgeons are divided over whether asymptomatic patients
should be treated with medication alone or should have surgery.
endarterectomy, the surgeon opens the artery and removes
the plaque. The plaque forms and enlarges in the inner layer
of the artery, or endothelium,
hence the name of the procedure which simply means removal
of the endothelium of the artery. A newer procedure, endovascular
and stenting, threads
a catheter up from the groin, around the aortic arch, and
up the carotid artery. The catheter uses a balloon to expand
the artery, and inserts a stent to hold the artery open.
In several clinical trials,the 30-day incidence of heart
attack, stroke, or death was significantly higher with stenting
than with endarterectomy (9.6% vs. 3.9%)
Carotid Revascularization Endarterectomy versus Stenting
funded by the National
Institutes of Health (NIH) reported that the results
of stents and endarterectomy were comparable. However, the
European International Carotid Stenting Study (ICSS)
found that stents had almost double the rate of complications.
aim of CEA is to prevent the adverse sequelae of carotid
artery stenosis secondary to atherosclerotic disease, i.e.
ischemic 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
CEA risks for combined 30 day mortality and stroke risk
should be < 3% for asymptomatic patients and less than
or equal to 6% for symptomatic patients. Symptomatic patients
typically have either transient ischemic attack (TIA) or
minor stroke, defined as a focal neurologic defect affecting
one side of the body, speech, or vision. Asymptomatic patients
have narrowing of their carotid arteries, but have not experienced
a TIA or stroke.
stenosis is diagnosed with ultrasound
doppler studies of the neck arteries, magnetic
resonance angiography (MRA) or computed
tomography angiography (CTA) or invasive angiography.
Revascularization of symptomatic stenoses has a much higher
index compared to asymptomatic lesions.
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 in
symptomatic patients. 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, where percent stenosis was defined
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
rate and hence benefit less from the procedure. For
maximum benefit patients should be operated on soon after
a TIA or stroke, preferably within the first 2 weeks.
stenosis = ( 1 - ( minimal diameter ) / ( poststenotic
diameter ) ) × 100%.
asymptomatic patients (those without TIA or strokes) 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. The key in
estimating the potential benefit for revascularization in
asymptomatic patients is understanding the natural history
of the disease, including the annual risk of stroke. Most
agree that the annual risk of stroke in patients with asymptomatic
carotid disease is between 1% and 2%, although some patients
are considered to be at higher risk such as those with ulcerated
plaques. In randomized trials of CEA compared to medication
therapy, it has been shown that stroke is reduced by surgery,
but the benefit does not appear for several years after
the surgery is performed. This is because there are peri-operative
complications (stroke and death) in the surgical patients.
The longer a patient lives after surgery magnifies the surgical
asymptomatic patients must be expected to survive at least
5 years after surgery to warrant accepting the risk of surgery.
Current surgical best-practice restricts surgery for asymptomatic
carotid stenosis to patients with greater than or equal
to 70% carotid stenosis if the surgery can be performed
with less than or equal to 3% risk of perioperative complications.
procedure cannot be performed in case of:
internal carotid artery obstruction (because there is
no benefit to treating chronic occlusion).
stroke on the ipsilateral
side with heavy sequelae, because there is no benefit
in preventing what has already happened, or risking
making it worse.
deemed unfit for the operation by the surgeon or anesthesiologist
due to co-morbidities.
risk criteria for CEA include the following:
less than or equal to 80 years.
III/IV congestive heart failure.
III/IV angina pectoris.
main or multi vessel coronary artery disease.
for open heart surgery within 30 days.
ventricular ejection fraction of less than or equal
(less than or equal to 30-day) heart attack.
lung disease or COPD.
cervical (C2) or intrathoracic lesion.
radical neck surgery or radiation therapy.
carotid artery occlusion.
laryngeal nerve injury.
depicting a Carotid Endarterectomy
incision is made on the midline side of the Sternocleidomastoid
muscle. The incision is between 5 and 10 cm in
length. The internal, common and external carotid arteries
are carefully identified, controlled with vessel loops,
and clamped. The lumen of the internal carotid artery is
opened, and the atheromatous plaque substance removed. The
artery is closed using suture
and a patch to increase the size of the lumen.
achieved, and the overlying layers closed with suture. The
skin can be closed with suture which may be visible or invisible
(absorbable). Many surgeons place 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
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
a wire-mesh stent and a device to protect the brain from
embolization of plaque material. The FDA has approved 7
carotid stent systems as safe and effective in patients
at increased risk of complications for carotid surgery and
1 carotid stent system for patients at average or usual
risk of carotid surgery. The SAPPHIRE study of patients
at high surgical risk for carotid surgery demonstrated non-inferiority
for carotid stenting compared to carotid surgery.
The CREST trial, the largest trial comparing carotid surgery
to carotid stenting in over 2,500 patients found that carotid
artery stenting resulted in a stroke rate of 6.4% versus
4.7% for endarterectomy at 4 years. However, carotid endarterectomy
was associated with a slightly higher rate of myocardial
infarction around the time of the procedure (2.3% versus
1.1%). Although the study's composite index including death,
stroke, and myocardial infarction is not significantly different
between the two groups, myocardial infarction was associated
with less impact on quality of life as compared with stroke
at one year.
is the consensus of experts in the field that carotid artery
stenting should be considered an option for high risk patients
who require carotid artery revascularization to prevent
patients to benefit from revascularization, the surgeon's
complication rate (30 day stroke and death) must remain
less than or equal to 3% for asymptomatic and less than
or equal to 6% of symptomatic patients. Other surgical complications
of the wound bed, which 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 fasciculations
developing on the tongue
and paralysis of the affected side: on sticking it out,
the patient's tongue will deviate toward the affected side.
Another rare but potentially serious complication is hyperperfusion
syndrome because of the sudden increase in perfusion
of the vasculature distal to stenosis.
endarterectomy procedure was developed and first done by
the Portuguese surgeon Joao Cid dos Santos in 1946, when
he operated an occluded superficial femoral artery, at the
of Lisbon. Later, surgical intervention to relieve atherosclerotic
obstruction of the carotid arteries was successfully performed
Michael DeBakey in 1953 for the first time, at the Methodist
Hospital in Houston, TX.
The first case to be recorded in the medical literature
was in The Lancet in 1954.
and the surgeon was Felix Eastcott, a consultant surgeon
and deputy director of the surgical unit at St
Mary's Hospital, London UK.
A reprint of his article together with a modern commentary
can be found on-line .
Eastcott's procedure was not strictly an endarterectomy
as we now understand it; he excised the diseased part of
the artery and then resutured the healthy ends together.
Since then, evidence for its effectiveness in different
patient groups has accumulated. In 2003 nearly 140,000 carotid
endarterectomies were performed in the USA (Halm).
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