Introduction
Carotid endarterectomy constitutes a significant surgical intervention aimed at mitigating the incidence of cerebrovascular accidents in individuals presenting with substantial carotid artery (CA) stenosis, predominantly attributable to the accumulation of atherosclerotic plaques. This operative procedure entails the excision of the plaque from the intimal surface of the CA, thereby re-establishing sufficient cerebral perfusion and diminishing the probability of embolic occurrences. As one of the most frequently executed vascular operations, carotid endarterectomy necessitates scrupulous adherence to surgical protocols to reduce the risk of complications and to guarantee favorable patient prognosis (1).
The surgical intervention, conventionally conducted under general anesthesia, requires meticulous anatomical visualization and deliberate dissection to effectively delineate the common CA (CCA), internal CA (ICA), and external CA (ECA). Intraoperative neuromonitoring techniques, which encompass somatosensory-evoked potentials (SSEP), motor-evoked potentials (MEP), and bispectral index (BIS), are integral to assessing the anesthetic depth and ensuring the patient’s safety throughout the operative procedure (2, 3).
The manuscript delineates the intricate surgical considerations associated with carotid endarterectomy, underscoring the criticality of appropriate patient positioning, meticulous arterial clamping, the excision of plaque, and the methodologies for arterial closure. Furthermore, it elaborates on the criteria guiding the judicious application of intraoperative shunting, contingent upon neuromonitoring feedback, in addition to the requisite postoperative care to vigilantly observe for potential complications and facilitate an uneventful recovery. Through a comprehensive and methodical approach, the ensuing content aspires to furnish an exhaustive guide for neurosurgeons and vascular surgeons undertaking carotid endarterectomy, accentuating optimal practices and pivotal considerations for attaining favorable surgical outcomes (4).
Preparation and anesthesia
Following pre-operative workup (Figure 1), surgical fitness is obtained by a neuroanesthesia team and consent is obtained. Patient is given general anesthesia, with an extended head and tilted to the opposite side. Intraoperative neuromonitoring is used including SSEP, MEP, and BIS to evaluate the depth of anesthesia.
Figure 1. (A–C) Preoperative contrast CT scan. (bone window) and 3D recon showing a calcified plaque at the CCA/ICA with luminal narrowing > 70%.
Incision
A longitudinal incision is made along the side of the neck, along the medial margin of the sternocleidomastoid. The incision is typically about 4–6 inches long.
Exposure of the CA
The skin, subcutaneous tissue, and underlying muscles are carefully separated to expose the CA. The artery is dissected free from surrounding tissues. The CCA, the ICA, and the ECA are exposed. It is important to expose the entire length of the plaque as well as a segment of the ICA beyond the plaque.
Clamping of the carotid arteries
Once the complete exposure of the required length is obtained, heparin 3000 IU is given intravenously. Then, ties are placed around the CCA, ICA, and ECA in case a bypass shunt is necessary. An elective shunt may be placed to maintain blood flow to the brain during the procedure; however, we do not use a shunt routinely in our patients. A shunt is placed only if the MEP and SSEP show a drop after clamping of the ICA. The clamping is performed in the following order—ICA, CCA, and ECA. The clamping is done either with a bulldog clamp or with multiple standard temporary aneurysm clips.
Artery incision
An incision is made along the CA to access the plaque. The plaque is carefully removed from the artery wall.
| Video 1. Carotid Endarterctomy: Surgical Nuances. https://youtu.be/wtz7RHXh3go |
Plaque removal
The plaque is carefully dissected and removed from the inner lining of the artery. The artery is inspected to ensure that all plaques are removed and the inner surface is smooth.
Closure of the artery
The artery is repaired, usually by closing the incision in the artery with 6’0 proline sutures. We rarely use a patch to augment closure.
Restoration of blood flow
The clamps are removed, in the reverse order of application, i.e., ECA, CCA, and then ICA. Blood flow is restored to the CA, which is measured with an intraoperative Doppler. The shunt, if used, is also removed.
Closure of the incision
The layers of tissue and skin are sutured back together. The incision is closed in layers, typically with absorbable sutures or staples.
Postoperative care
The patient is monitored for complications such as bleeding, infection, or changes in neurological function. Medications and follow-up care are provided to support recovery and prevent complications. A postoperative CT angiography (Figure 2) is performed to document plaque removal.
Figure 2. (A,B) Post-operative CT with 3D Recon showing complete plaque removal.
Conflict of Interest
The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
References
1. Paramasivan NK, Sylaja PN, Pitchai S, Madathipat U, Sreedharan SE, Sukumaran S, et al. Carotid endarterectomy for symptomatic carotid stenosis: differences in patient profile in a low-middle-income country. Cerebrovasc Dis Extra. (2022) 13:56–62. doi: 10.1159/000528515
2. Saha SP, Saha S, Vyas KS. Carotid endarterectomy: current concepts and practice patterns. Int J Angiol Off Publ Int Coll Angiol Inc. (2015) 24:223–35. doi: 10.1055/s-0035-1558645
3. Uno M, Takai H, Yagi K, Matsubara S. Surgical technique for carotid endarterectomy: current methods and problems. Neurol Med Chir (Tokyo). (2020) 60:419–28. doi: 10.2176/nmc.ra.2020-0111
4. Misra BK, Purandare HR, Ved R, Ashok PP. Carotid endarterectomy: results and long-term follow-up of a single institution. Neurol India. (2011) 59:390–6. doi: 10.4103/0028-3886.82746.
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