A 68-year-old man with a history of transient ischemic attacks presented for carotid endarterectomy (CEA).
What are indications for carotid endarterectomy?
CEA reduces the risk of stroke in symptomatic patients with significant carotid artery stenosis. Symptomatic patients with >70% luminal narrowing of the carotid artery had improved outcome after surgery compared with patients receiving medical treatment alone. Symptoms include transient ischemic attack, reversible ischemic neurologic deficit, and nondisabling stroke. Asymptomatic patients with significant luminal narrowing are considered for CEA if the risk of perioperative morbidity and mortality is low.
What is the alternative to carotid endarterectomy?
Carotid artery angioplasty with placement of an arterial stent is a reasonable alternative treatment for carotid artery stenosis. This technique involves placing an endovascular catheter, usually from the femoral artery, with fluoroscopic guidance, through the great arteries and heart to the carotid artery. Balloon dilation of the stenosis is performed. A filter or other device may be temporarily positioned distal to the lesion to limit embolization of material to the brain. After angioplasty, a stent is positioned at the site to maintain arterial patency. The safety and efficacy of angioplasty with stent placement compare favorably with surgical treatment. It may be the only practical treatment for cases of high-grade carotid stenosis in which the lesion is located distally and poorly accessible to surgery.
What are the most serious perioperative complications associated with carotid endarterectomy?
The most serious perioperative complications of carotid surgery are neurologic and cardiac. Neurologic complications include cerebral infarction, transient ischemia, and cognitive dysfunction. Cardiovascular complications include cardiac ischemia, dysrhythmia, hypotension, hypertension, and myocardial infarction. Ischemic cerebral injury may result from embolization of thrombus or air during surgical manipulation. It may also result from decreased cerebral perfusion during temporary carotid artery occlusion. Arterial stenosis or occlusion after CEA may also produce an ischemic insult. Patients with atherosclerotic disease of the carotid arteries often have similar pathology of coronary vessels.