Chapter 9: Carotid Endarterectomy PPT

What occurs with a traditional carotid endarterectomy (CEA)?

• It’s an open operation.

• Arteriotomy is made through internal carotid artery (ICA).

• Atheromatous material is removed.

• Arteriotomy is closed.

What is the primary closure of a CEA?

The arterial wall only.

What is the patch closure of a CEA?

The patch is used to enlarge the closure area.

What are the common problems associated with the CEA?

• Common problems are visualized more at the distal ICA border

• Narrowing as a result of closure

• Plaque retained from incomplete excision

• Neointimal hyperplasia at surgical site (restenosis)

What is the primary concern after a CEA?

Restenosis.

oResidual plaque

oSuture narrowing

oThrombotic narrowing/occlusion

What should also be inspected after a CEA?

The entire endarterectomy site, as well as paying particular attention to the distal end.

• Information may be difficult to gather immediately postoperatively

What should be asked from a patient who has a history of having a CEA surgery?

Ask about what type of patch they have (if used).

oDacron patch has woven appearance.

oPolytetrafluoroethylene (PTFE) has two brightly echogenic lines.

oVein patch closely resembles native vessel.

If information is unavailable, assume traditional repair with patch.

Figure 9-2 Normal Endarterectomy Dacron patch

Along the superficial wall of endarterectomy site

Figure 9-2 Abnormal Dacron patch

With buckling of the patch and hypoechoic mass (arrow) suggestive of extraluminal fluid collection providing evidence of infection.

Figure 9-3 Post-CEA carotid intimal flap

Grayscale image with defect projecting into lumen along anterior wall of the ICA.

Figure 9-3 Post-CEA carotid intimal flap

Color-flow imaging noting turbulence along the area of the flap.

What are stenotic problems?

oWithin 1 month postoperative, stenosis considered surgical problems

• Narrowing of primary closure

• Remnant plaque (shelf lesion)

• Thrombus from surgical manipulations

What is restenosis?

—Narrowing in the first 24 months considered neointimal hyperplasia

• Relatively benign; low thromboembolic risk

• Has potential to quickly lead to occlusion

After 2 years, what is stenosis considered as?

Atherosclerotic.

• Risks similar to asymptomatic lesions.

oSome labs adjust stenosis criteria post-CEA but most will use preprocedure criteria

oPostoperative surveillance is always bilateral.

Where is catheter access for CAS (Carotid Artery Stenting) usually through?

At the common femoral artery.

Complications can occur not only in carotid system but in pathway of catheter and may include:

• Dissection

• Thrombosis

• Perforations

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