Carotid endarterectomy

More recent reports conclude that early CEA after a nondisabling ischemic stroke can be performed with perioperative mortality and stroke rates comparable to those of delayed CEA. In a subgroup analysis by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) investigators, 42 patients who underwent early CEA (<30 days after stroke) were compared with 58 patients who underwent delayed CEA (>30 days), and no overall difference was demonstrated in the perioperative stroke rate (4.8% vs. 5.2%). Another recent prospective randomized study of 86 patients showed no difference in either perioperative stroke (2% in both groups) or survival rates (mean 23 months follow-up) between patients randomized to early or delayed CEA. ... 

Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1991 325 445 53. 

Aleksic M, Rueger MA, Lehnhardt EG, Sobesky J, Matoussevitch V, Neveling M, Heiss WD, Bmnkwall J, Jacobs AH. Primary stroke unit treatment followed by very early carotid endarterectomy for carotid artery stenosis after acute stroke. Cerebrovasc Dis 2006 22 276-281. 

Ballotta E, Da Giau G, Baracchini C, Abbnizzese E, Saladini M, Meneghetti G. Early versus delayed carotid endarterectomy after a nondisabling ischemic stroke a prospective randomized study. Surgery 2002 131 287-293. 

McPherson CM, Woo D, Cohen PL, Panciob AM, Kissela BM, CarrozzeUa JA, Tomsick TA, ZuccareUo M. Early carotid endarterectomy for critical carotid artery stenosis after thrombolysis therapy in acute ischemic stroke in the middle cerebral artery. Stroke 2001 32 2075-2080. 

Krishnamurthy S, Tong D, McNamara KP, Steinberg GK, Cockroft KM. Early carotid endarterectomy after ischemic stroke improves diffusion/perfusion mismatch on magnetic resonance imaging report of two cases. Neurosurgery 2003 52 238-241 [discussion 242]. 

Caplan LR, Skilhnan J, Ojemann R, Eields WS. Intracerebral hemorrhage following carotid endarterectomy a h3fpertensive complication Stroke 1978 9 457-460. 

Gasecki AP, Eerguson GG, EUasziw M, Clagett GP, Pox AJ, Hachinski V, Barnett HJ. Early endarterectomy for severe carotid artery stenosis after a nondisabling stroke Results from the North American symptomatic carotid endarterectomy trial. J Vase Surg 1994 20 288-295. 

Barnett HJ, Meldrum HE, EUasziw M. The appropriate use of carotid endarterectomy. CMAJ 2002 166 1169-1179. 

Findlay JM, Marchak BE, Pelz DM, Eeasby TE. Carotid endarterectomy a review. Can J Neurol Sci 2004 31 22-36. 

Heros RC. Carotid endarterectomy in patients with intraluminal thrombus. Stroke 1988 19 667-668. 

Clinical trials and meta-analyses have demonstrated that early carotid endarterectomy (CEA) is the preferred treatment for most patients with severe symptomatic internal carotid artery (ICA) stenosis and selected patients with moderate disease.However, CEA is often delayed in chnical practice, or may not be appropriate in some patients due to an unfavorable risk-benefit profile. In these settings, it is reasonable to consider acute antithrombotic treatment to prevent early recurrent stroke. 

Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB, Rankin RN, Clagett GP, Hachinski VC, Sackett DL, Thorpe KE, Meldrum HE, Spence JD. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1998 339(20) 1415-1425. 

Suwanwela N, Can U, Furie KL, Southern JF, Macdonald NR, Ogilvy CS, Hansen CJ, Buonanno FS, Abbott WM, Koroshetz WJ, Kistler JR Carotid Doppler ultrasound criteria for internal carotid artery stenosis based on residual lumen diameter calculated from en bloc carotid endarterectomy specimens. Stroke 1996 27(11) 1965-1969. 

Patel SG, Collie DA, Wardlaw JM, Lewis SC, Wright AR, Gibson RJ, Sellar RJ. Outcome, observer reliability, and patient preferences if CTA, MRA, or Doppler ultrasound were used, individually or together, instead of digital subtraction angiography before carotid endarterectomy. J Neurol Neurosurg Psychiatry 2002 73(l) 21-28. 

Johnston DC, Goldstein LB. Clinical carotid endarterectomy decision making noninvasive vascular imaging versus angiography. Neurology 2001 56(8) 1009-1015. 

Norris JW, Halliday A. Is ultrasound sufficient for vascular imaging prior to carotid endarterectomy Stroke 2004 35(2) 370-371. 

Carotid Endarterectomy and Middle Cerebral Artery Embolectomy... 

It is unknown whether carotid endarterectomy is of value when performed emergently after stroke, meaning within the first 24 hours after symptoms begin.9 It appears that patients with mild to moderate neurologic deficits, crescendo TIAs or stroke-in-evolution can be operated on safely within the first few hours after the onset of symptoms. Patients with more severe neurologic deficits should only be considered for carotid endarterectomy when the procedure can be performed within the first few hours after the onset of symptoms. It is not indicated for patients with permanent deficits from a moderate to severe completed stroke. 

The benefit of carotid endarterectomy for prevention of recurrent stroke has been studied previously in major trials.25,26 A recent meta-analysis has been completed that has combined these clinical trials to evaluate 6,092 patients.27 Carotid endarterectomy has been shown to be beneficial for preventing ipsilateral stroke in patients with symptomatic carotid artery stenosis of 70% or greater and is recommended in these patients. In patients with symptomatic stenosis of 50% to 69%, a moderate reduction in risk is seen in clinical trials. In all patients with stenosis of 50% to 69% and a recent stroke, carotid endarterectomy is appropriate. In other patients, surgical risk factors and surgeon skill should be considered prior to surgery. The patient should have, at a minimum, a life expectancy of 5 years, and the surgical risk of stroke and/or death should be less than 6%. Carotid endarterectomy is not beneficial for symptomatic carotid stenosis less than 50% and should not be considered in these patients. 

There are data to suggest that patients with asymptomatic carotid artery stenosis of 60% or more benefit from carotid endarterectomy if it is performed by a qualified surgeon with low complication rates (less than 3%). At this time, there is considerable controversy over how this information can be applied to clinical practice. A current review recommends considering carotid endarterectomy in patients with carotid artery stenosis... 

Chaturvedi A, Bruno A, Feasby T, et al. Carotid endarterectomy—an evidence-based review. Neurology 2005 65 794-801. 

It has also been suggested that terlipressin has vasoconstrictor activity within the splanchnic vascular territory (21). Hypotension developed under general anesthesia in 32 patients undergoing carotid endarterectomy treated with renin-angiotensin inhibitors (22). They were randomized to received terlipressin 1 mg (n = 16) or noradrenaline infusion. Compared with baseline those who received terlipressin had reduced gastric mucosal perfusion for at least 4 hours. There was also reduced oxygen delivery and oxygen consumption index at 30 minutes and 4 hours in those who received terlipressin. 

CHD = myocardial infarction (Ml), significant myocardial ischemia (angina), history of coronary artery bypass graft (CABG), history of coronary angioplasty, angiographic evidence of lesions, carotid endarterectomy, abdominal aortic aneurysm, peripharal vascular disease (claudication), thrombotic/embolic stroke, transient ischemic attack (TIA)... 

Decision-making in the management of carotid artery stenosis based upon symptom status, lesion severity, and estimated procedural risks. The conventional paradigm for treatment assignment is depicted in the top panel. The proposed new paradigm in the bottom panel. Abbreviation CEA, carotid endarterectomy. 

Withlow R Registry Study to evaluate the Neuroshield Bare-Wire Cerebral Protection System and X-Act Stent in patients at high risk for Carotid Endarterectomy (SECuRITY). Presented at the Annual Transcatheter Therapeutics Scientific Sessions, Washington, DC, September 2003. 

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