Background
Carotid endarterectomy (CEA) is a surgical procedure that involves the removal of plaque from the carotid arteries. Carotid arteries are the two major arteries located in the neck, which branch off from the aorta and supply blood to the brain. Plaque formation in the carotid arteries can result in stroke or transient ischemic attack (TIA). This extracranial atherosclerosis, or blockage in the arteries that supply blood to the brain, accounts for 15%–20% of all ischemic strokes. All patients presenting to the hospital with ischemic stroke or TIA should be worked up for carotid artery disease. Patients with carotid artery stenosis of ≥70% can be considered for CEA for prevention of future stroke.
How to Use It
All patients admitted to the hospital for ischemic stroke or TIA workup should be screened for carotid artery stenosis via carotid duplex ultrasonography, a noninvasive and sensitive method for detecting the disease. Patients with carotid artery blockage of ≥70% can benefit from CEA for prevention of future strokes, especially patients presenting with TIA. Prior to CEA, carotid artery stenosis should be correlated by at least one additional imaging resource such as magnetic resonance angiography (MRA) or computed tomography (CT) angiography. Asymptomatic patients can be screened for carotid artery stenosis by auscultating the carotid arteries. Presence of carotid bruits during physical examination should prompt further workup for carotid artery disease.
How It Is Done
CEA is usually performed by a vascular surgeon. The procedure can be performed under local or general anesthesia, although most physicians prefer performing the procedure under general anesthesia. Recommendations for fasting when using general anesthesia can be found in Chapter 6: Introduction to Anesthesia . The incision is made on the side of the neck along the blocked carotid artery. The surgeon makes an incision from behind the ear to above the collarbone. The blood supply to the carotid artery is clamped and a shunt is placed to enable cerebral blood circulation during the procedure. The carotid artery is incised, and the plaque is cut and removed from within the artery. There is a variation of surgical techniques that can be used to close the carotid artery incision. Many surgeons choose to close the artery using a patch to increase the diameter of the artery. This has implications for improving carotid artery blood flow for the affected artery, reducing residual or recurrent stenosis. Patch closure, however, also carries an increased risk of thrombosis due to additional time required to suture the patch. A specific surgical approach has not been proven to be beneficial. The preferred method depends on surgeon preference. , After the procedure, the patient may be transferred to an intensive care unit (ICU) or an inpatient service. Close neurologic monitoring may be required during the first 24 hours post-procedure. Most patients can be discharged 1–2 days after the procedure.
Medication Implications
BEFORE THE PROCEDURE
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Perioperative medical optimization of the patient includes the following:
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Antithrombotic therapy: all patients should be initiated on aspirin 81–325 mg daily and continued before and after the surgical procedure. Patients allergic to aspirin can be initiated on clopidogrel 75 mg daily. The decision to discontinue clopidogrel prior to CEA should be made on a case-by-case basis ,
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Blood pressure goal is ≤140/80 mmHg
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Beta blockade heart rate goal is 60–80 beats/minute
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Statin therapy: patients should be initiated on a statin for plaque stabilization prior to the procedure. There is no optimal dose or agent recommended for initiation prior to CEA at this time. Intensive lipid-lowering therapy with a high-potency statin (e.g., atorvastatin 80 mg orally daily) may be recommended for most patients post-stroke or TIA for secondary prevention of stroke , ,
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CEA is often an elective procedure; therefore, oral anticoagulation should be discontinued prior to the procedure. For patients receiving warfarin, target international normalized ratio (INR) prior to surgery has not been defined and may be surgeon-dependent. Direct oral anticoagulation (e.g., dabigatran, apixaban, rivaroxaban, and edoxaban) are generally discontinued 1–3 days prior to the surgery but varies on a number of factors, namely renal function. See Chapter 4: Anticoagulation Management in the Periprocedural Period for more details.
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Preoperative infectious prophylaxis should include administration of cefazolin 2 g (3 g for patients weighing ≥120 kg) or cefuroxime 1.5 g infused intravenously 1 hour prior to the surgical incision. Patients with a beta-lactam allergy can be administered vancomycin. Vancomycin 15 mg/kg (maximum of 2000 mg) should be administered intravenously 2 hours before surgical incision due to the longer time required to complete the infusion (maximum of 500 mg per 30 minutes). Infectious prophylaxis should be discontinued within 24 hours postoperatively.
DURING THE PROCEDURE
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Surgeons may administer heparin 3000–5000 units intravenously prior to clamping the carotid artery during the procedure.
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There is debate whether protamine needs to be administered to reduce the risk of neck hematoma after the procedure. One concern is that the administration of protamine may lead to an increased risk of thrombosis after the procedure. Therefore, administration of protamine is based on patient risk factors and surgeon preference. ,
AFTER THE PROCEDURE
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Postoperative hypertension can lead to increased risk of neck hematoma. It is recommended to maintain systolic blood pressure <170 mmHg in the postoperative period. Medications such as labetalol 10–20 mg or hydralazine 10 mg via intravenous push can be utilized to treat uncontrolled hypertension in the first 24 hours postoperatively.
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Baroreceptor reflex responses such as bradycardia, hypotension, and vasovagal reactions occur in 5% to 10% of the cases. The response is usually self-limiting and often does not require an intervention postoperatively.
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There is a small possibility (less than 1% of cases) that a clot can break off during surgery and cause a cerebrovascular event. Therefore, close neurologic evaluation postoperatively is recommended for all patients to monitor for signs and symptoms of stroke. Patients may be transferred to an ICU during the first 24 hours postoperatively for close neurologic monitoring.
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Medical therapy initiated for medical optimization prior to the surgical procedure, such as aspirin, beta blockade, and statin therapy, should be continued postoperatively once the patient is able to tolerate enteral medications (see details in “Before the procedure,” above).
References
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