Carotid endarterectomy: Difference between revisions
→Asymptomatic: asymptomatic indications are tricky |
→Procedure: move ref |
||
| Line 71: | Line 71: | ||
Minimally invasive procedures have been developed, by threading catheters through the [[femoral artery]], up through the [[aorta]], then inflating a balloon to dilate the carotid artery, with a wire-mesh stent and a device to protect the brain from embolization of plaque material. The FDA has approved 7 carotid stent systems as safe and effective in people at increased risk of complications for carotid surgery and 1 carotid stent system for people at average or usual risk of carotid surgery. A study of people at high surgical risk for carotid surgery demonstrated non-inferiority for carotid stenting compared to carotid surgery.<ref>{{cite journal |author=Yadav JS |title=Protected carotid-artery stenting versus endarterectomy in high-risk patients |journal=N. Engl. J. Med. |volume=351 |issue=15 |pages=1493–1501 |date=October 2004 |pmid=15470212 |doi=10.1056/NEJMoa040127 |url= |author2=Wholey MH |author3=Kuntz RE |display-authors=3 |last4=Fayad |first4=Pierre |last5=Katzen |first5=Barry T. |last6=Mishkel |first6=Gregory J. |last7=Bajwa |first7=Tanvir K. |last8=Whitlow |first8=Patrick |last9=Strickman |first9=Neil E.}}</ref> The CREST trial, the largest trial comparing carotid surgery to carotid stenting in over 2,500 people found that carotid artery stenting resulted in a stroke rate of 6.4% versus 4.7% for endarterectomy at 4 years. However, carotid endarterectomy was associated with a slightly higher rate of myocardial infarction around the time of the procedure (2.3% versus 1.1%). Although the study's composite index including death, stroke, and myocardial infarction is not significantly different between the two groups, myocardial infarction was associated with less impact on quality of life as compared with stroke at one year.<ref>{{cite journal | vauthors = Brott TG, ((Hobson RW 2nd)), ((Howard G ''et al.'')) | year = 2010 | title = Stenting versus endarterectomy for treatment of carotid-artery stenosis | doi = 10.1056/NEJMoa0912321 | pmid = 20505173 | journal = N Engl J Med | volume = 363 | issue = | pages = 11–23 | pmc = 2932446 }}</ref> |
Minimally invasive procedures have been developed, by threading catheters through the [[femoral artery]], up through the [[aorta]], then inflating a balloon to dilate the carotid artery, with a wire-mesh stent and a device to protect the brain from embolization of plaque material. The FDA has approved 7 carotid stent systems as safe and effective in people at increased risk of complications for carotid surgery and 1 carotid stent system for people at average or usual risk of carotid surgery. A study of people at high surgical risk for carotid surgery demonstrated non-inferiority for carotid stenting compared to carotid surgery.<ref>{{cite journal |author=Yadav JS |title=Protected carotid-artery stenting versus endarterectomy in high-risk patients |journal=N. Engl. J. Med. |volume=351 |issue=15 |pages=1493–1501 |date=October 2004 |pmid=15470212 |doi=10.1056/NEJMoa040127 |url= |author2=Wholey MH |author3=Kuntz RE |display-authors=3 |last4=Fayad |first4=Pierre |last5=Katzen |first5=Barry T. |last6=Mishkel |first6=Gregory J. |last7=Bajwa |first7=Tanvir K. |last8=Whitlow |first8=Patrick |last9=Strickman |first9=Neil E.}}</ref> The CREST trial, the largest trial comparing carotid surgery to carotid stenting in over 2,500 people found that carotid artery stenting resulted in a stroke rate of 6.4% versus 4.7% for endarterectomy at 4 years. However, carotid endarterectomy was associated with a slightly higher rate of myocardial infarction around the time of the procedure (2.3% versus 1.1%). Although the study's composite index including death, stroke, and myocardial infarction is not significantly different between the two groups, myocardial infarction was associated with less impact on quality of life as compared with stroke at one year.<ref>{{cite journal | vauthors = Brott TG, ((Hobson RW 2nd)), ((Howard G ''et al.'')) | year = 2010 | title = Stenting versus endarterectomy for treatment of carotid-artery stenosis | doi = 10.1056/NEJMoa0912321 | pmid = 20505173 | journal = N Engl J Med | volume = 363 | issue = | pages = 11–23 | pmc = 2932446 }}</ref> |
||
It is the consensus of experts in the field that carotid artery stenting should be considered an option for high risk patients who require carotid artery revascularization to prevent stroke.<ref>{{cite journal |vauthors=White CJ, Beckman JA, Cambria RP, Comerota AJ, Gray WA, Hobson RW, Iyer SS | year = 2008 | title = Atherosclerotic Peripheral Vascular Disease Symposium II: controversies in carotid artery revascularization | url = | journal = Circulation | volume = 118 | issue = 25| pages = 2852–2859 | doi=10.1161/circulationaha.108.191175 | pmid=19106407| doi-access = free |
It is the consensus of experts in the field that carotid artery stenting should be considered an option for high risk patients who require carotid artery revascularization to prevent stroke.<ref>{{cite journal |vauthors=White CJ, Beckman JA, Cambria RP, Comerota AJ, Gray WA, Hobson RW, Iyer SS | year = 2008 | title = Atherosclerotic Peripheral Vascular Disease Symposium II: controversies in carotid artery revascularization | url = | journal = Circulation | volume = 118 | issue = 25| pages = 2852–2859 | doi=10.1161/circulationaha.108.191175 | pmid=19106407| doi-access = free }}</ref> |
||
==History== |
==History== |
||
Revision as of 19:42, 28 May 2020
 | This article includes a list of general references, but it lacks sufficient corresponding inline citations. (July 2019) |
| Carotid endarterectomy | |
|---|---|
 Carotid endarterectomy specimen. The specimen is removed from within the lumen of the common carotid artery (bottom), and the internal carotid artery (left) and external carotid artery (right). | |
| ICD-9-CM | 38.1 |
| MeSH | D016894 |
Carotid endarterectomy (CEA) is a surgical procedure done to reduce the risk of stroke from carotid artery stenosis (narrowing the internal carotid artery).
In endarterectomy, the surgeon opens the artery and removes the plaque. The plaque forms and enlarges in the inner layer of the artery, or endothelium, hence the name of the procedure which simply means removal of the endothelium of the artery.
Medical uses
Carotid endarterectomy is used to treat carotid artery stenosis, which can either have symptoms (ie, be symptomatic), or be found by a doctor without having symptoms (asymptomatic).
Symptomatic
In symptomatic people for every six people treated, one major stroke would be prevented at two years (i.e. a number needed to treat (NNT) of six) for symptomatic people with a 70–99% stenosis, where percent stenosis was defined as:[1]
- percent stenosis = ( 1 − ( minimal diameter ) / ( poststenotic diameter ) ) × 100%.
Symptomatic people with less severe carotid occlusion (50–69%) had a smaller benefit, with a NNT of 22 at five years. In addition, co-morbidity adversely affects the outcome; people with multiple medical problems have a higher post-operative mortality rate and hence benefit less from the procedure. For maximum benefit people should be operated on soon after a TIA or stroke, preferably within the first 2 weeks.[1]
NICE and other guidelines also recommend that patients with symptomatic carotid stenosis be given carotid endarterectomy urgently, since the greatest risk of stroke is within days. Carotid endarterectomy reduces the risk of stroke or death from carotid emboli by about half.
The aim of CEA is to prevent ischemic stroke. As with any prevantative operation, careful evaluation of the relative benefits and risks of the procedure is required. Perioperative risks for combined 30-day mortality and stroke risk should be < 3% for asymptomatic people and ≤ 6% for symptomatic people. Symptomatic people typically have either transient ischemic attack (TIA) or minor stroke, defined as a focal neurologic defect affecting one side of the body, speech, or vision. Asymptomatic people have narrowing of their carotid arteries, but have not experienced a TIA or stroke.
Asymptomatic
The annual risk of stroke in patients with asymptomatic carotid disease is between 1% and 2%, although some patients are considered to be at higher risk, such as those with ulcerated plaques. This low rate of stroke means that there is less potential stroke risk-reduction from endarterectomy for asymptomatic patients relative to symptomatic patients. However, carotid endarterectomy plus treatment with a statin medicine and anti-platelet therapy does reduces stroke risk further than medication alone in the five years following surgery for asymptomatic patients with severe carotid stenosis.[2]
Complications
The most feared complication of carotid endarterectomy is stroke. Risks of stroke at the time of surgery are higher for symptomatic (3-5%) than asymptomatic patients (1-3%).
Bleeding, infection, and cranial nerve injury are also risks at the time of surgery. Following surgery, a rare early complication is cerebral hyperperfusion syndrome, also known as reperfusion syndrome, which is associated with headache and high blood pressure following surgery.
Long term complications include restenosis of the endarterectomy bed, although the clinical significance of this is controversial in asymptomatic patients.
Contraindications
The procedure is not necessary when:
- There is complete internal carotid artery obstruction (because there is no benefit to treating chronic occlusion).
- The person has a previous complete hemispheric stroke on the ipsilateral and complete cerebrovascular territory side severe neurologic deficits (NIHSS>15), because there is no brain tissue at risk for further damage.
- People deemed unfit for the operation by the surgeon or anesthesiologist due to comorbidities.
High risk criteria for CEA include the following:
- Age ≥80 years.
- Class III/IV congestive heart failure.
- Class III/IV angina pectoris.
- Left main or multi vessel coronary artery disease.
- Need for open heart surgery within 30 days.
- Left ventricular ejection fraction of ≤30%.
- Recent (≤30-day) heart attack.
- Severe lung disease or COPD.
- Severe renal disease.
- High cervical (C2) or intrathoracic lesion.
- Prior radical neck surgery or radiation therapy.
- Contralateral carotid artery occlusion.
- Prior ipsilateral CEA.
- Contralateral laryngeal nerve injury.
- Tracheostoma.
Carotid artery stenting is an alternative to carotid endarterectomy in cases where endarterectomy is considered too risky.
Procedure
An incision is made on the midline side of the sternocleidomastoid muscle. The incision is between 5 and 10 cm in length. The internal, common and external carotid arteries are carefully identified, controlled with vessel loops, and clamped. The lumen of the internal carotid artery is opened, and the atheromatous plaque substance removed. The artery is closed using suture and a patch to increase the size of the lumen. Hemostasis is achieved, and the overlying layers closed with suture. The skin can be closed with suture which may be visible or invisible (absorbable). Many surgeons place a temporary shunt to ensure blood supply to the brain during the procedure. The procedure may be performed under general or local anaesthesia. The latter allows for direct monitoring of neurological status by intra-operative verbal contact and testing of grip strength. With general anaesthesia, indirect methods of assessing cerebral perfusion must be used, such as electroencephalography (EEG), transcranial doppler analysis and carotid artery stump pressure monitoring. At present there is no good evidence to show any major difference in outcome between local and general anaesthesia.
Minimally invasive procedures have been developed, by threading catheters through the femoral artery, up through the aorta, then inflating a balloon to dilate the carotid artery, with a wire-mesh stent and a device to protect the brain from embolization of plaque material. The FDA has approved 7 carotid stent systems as safe and effective in people at increased risk of complications for carotid surgery and 1 carotid stent system for people at average or usual risk of carotid surgery. A study of people at high surgical risk for carotid surgery demonstrated non-inferiority for carotid stenting compared to carotid surgery.[3] The CREST trial, the largest trial comparing carotid surgery to carotid stenting in over 2,500 people found that carotid artery stenting resulted in a stroke rate of 6.4% versus 4.7% for endarterectomy at 4 years. However, carotid endarterectomy was associated with a slightly higher rate of myocardial infarction around the time of the procedure (2.3% versus 1.1%). Although the study's composite index including death, stroke, and myocardial infarction is not significantly different between the two groups, myocardial infarction was associated with less impact on quality of life as compared with stroke at one year.[4]
It is the consensus of experts in the field that carotid artery stenting should be considered an option for high risk patients who require carotid artery revascularization to prevent stroke.[5]
History
The endarterectomy procedure was developed and first done by the Portuguese surgeon Joao Cid dos Santos in 1946, when he operated an occluded superficial femoral artery, at the University of Lisbon. In 1951 an Argentinian surgeon repaired a carotid artery occlusion using a bypass procedure. The first endarterectomy was successfully performed by Michael DeBakey around 1953, at the Methodist Hospital in Houston, TX, although the technique was not reported in the medical literature until 1975.[6] The first case to be recorded in the medical literature was in The Lancet in 1954;[6][7] the surgeon was Felix Eastcott, a consultant surgeon and deputy director of the surgical unit at St Mary's Hospital, London, UK.[8] Eastcott's procedure was not strictly an endarterectomy as we now understand it; he excised the diseased part of the artery and then resutured the healthy ends together.[citation needed] Since then, evidence for its effectiveness in different patient groups has accumulated. In 2003 nearly 140,000 carotid endarterectomies were performed in the USA.[citation needed]
References
- ^ a b Orrapin, S; Rerkasem, K; Reynier, P; Secrest, MH; Eisenberg, MJ; Filion, KB (7 June 2017). "Carotid endarterectomy for symptomatic carotid stenosis". The Cochrane database of systematic reviews. 6: CD001081. doi:10.1002/14651858.CD001081.pub3. PMID 28590505.
- ^ Moresoli, P; Habib, B; Reynier, P; Secrest, MH; Eisenberg, MJ; Filion, KB (August 2017). "Carotid Stenting Versus Endarterectomy for Asymptomatic Carotid Artery Stenosis: A Systematic Review and Meta-Analysis". Stroke. 48 (8): 2150–2157. doi:10.1161/STROKEAHA.117.016824. PMID 28679848.
- ^ Yadav JS; Wholey MH; Kuntz RE; et al. (October 2004). "Protected carotid-artery stenting versus endarterectomy in high-risk patients". N. Engl. J. Med. 351 (15): 1493–1501. doi:10.1056/NEJMoa040127. PMID 15470212.
- ^ Brott TG, Hobson RW 2nd, Howard G et al. (2010). "Stenting versus endarterectomy for treatment of carotid-artery stenosis". N Engl J Med. 363: 11–23. doi:10.1056/NEJMoa0912321. PMC 2932446. PMID 20505173.
- ^ White CJ, Beckman JA, Cambria RP, Comerota AJ, Gray WA, Hobson RW, Iyer SS (2008). "Atherosclerotic Peripheral Vascular Disease Symposium II: controversies in carotid artery revascularization". Circulation. 118 (25): 2852–2859. doi:10.1161/circulationaha.108.191175. PMID 19106407.
- ^ a b Friedman, SG (December 2014). "The first carotid endarterectomy". Journal of Vascular Surgery. 60 (6): 1703–8.e1–4. doi:10.1016/j.jvs.2014.08.059. PMID 25238726.
- ^ Eastcott, HH; Pickering, GW; Rob, CG (13 November 1954). "Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia". Lancet. 267 (6846): 994–6. doi:10.1016/S0140-6736(54)90544-9. PMID 13213095.
- ^ "Felix Eastcott, arterial surgeon". The Times. London. 2009-12-31.