ISCHEMIC STROKE / PREVENTION
Carotid endarterectomy (CEA)
Created 31/01/2023, last revision 21/04/2023
- CEA is the gold standard for the management of significant carotid stenosis (both symptomatic and asymptomatic)
- an alternative to CEA represents carotid angioplasty and stenting (CAS)
- long-term effect is the same for CEA and CAS (annual risk of ipsilateral stroke approx. 0.6 and 0.64% respectively), periprocedural complications are higher with CAS [Brott, 2019]
- CEA appears to be preferable to CAS in patients ≥ 70 years of age, and both procedures are comparable in younger patients [Müller, 2020] (AHA/ASA 2021 2a/B-R)
- the benefit of transcarotid revascularization (TCAR) is unclear (AHA/ASA 2021 2b/B-NR)
- the decision to revascularize should be made by a team that includes a neurologist, neurosurgeon/vascular surgeon, and/or interventional radiologist
Indications
Acute symptomatic carotid occlusion
- consider IVT or MT → recanalization therapy for acute stroke
- emergent CEA
- patients ineligible for standard recanalization procedures
- patients with mild deficits and small ischemia who are at acute risk of hypoperfusion – efficacy is not proven (AHA/ASA 2018 IIb/B-NR)
- CEA indication is supported by the absence of intracranial occlusion (suitable for combined endovascular procedures), low flow in MCA on TCD/TCCD and/or significant MR DWI/PWI mismatch
- ICA occlusion in the absence of intracranial occlusion is not amenable to endovascular treatment due to the high risk of periprocedural distal embolization
- acute surgical revision of post-procedural acute ICA thrombosis (intracranial embolization must be excluded)
Symptomatic carotid stenosis
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Asymptomatic carotid stenosis
Symptomatic carotid stenosis – specific situations
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Timing
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Arrangements before surgery
- assess carotid stenosis – usually, neurosonology in combination with CTA (or MRA) is used; DSA is less common
- severity of stenosis and its etiology
- high-risk plaque characteristics?
- collateral circulation and contralateral ICA status?
→ measurement of stenosis on CTA (according to NASCET)
→ quantification of stenosis by ultrasound
→ assessment of intracranial flow including vasomotor reactivity
- consider the infarct characteristics on imaging (CT/MR) and neurological deficit (incl. NIHSS)
- stenosis symptomatic or asymptomatic?
- recent or older infarct?
- what is its extent?
- is it relevant to carotid stenosis?
- is there a hemorrhagic component?
- a history and preoperative physical examination (myocardial infarction is the most common cause of death after CEA and the most common non-neurological complication)
- physical examination
- ECG
- TTE
- coronarography or TEE in selected cases
- proper correction of hypertension in the perioperative period is critical (to reduce the risk of hyperperfusion syndrome)
- do not interrupt antiplatelet and statin therapy ( (the effect is mainly seen in symptomatic stenoses) (AHA/ASA I/A)
- all patients scheduled for carotid surgery should receive 81-325 mg of aspirin or 75 mg of clopidogrel daily; therapy should continue life-long (AHA/ASA 2011 I/A)
- the ACE (ASA and Carotid Endarterectomy Trial) tested ASA at doses 81 mg, 325 mg, 650 mg, or 1300 mg
- n= 2849 patients
- therapy was started before CEA and continued for three months after the procedure
- 81-325mg of ASA reduced the risk of stroke, myocardial infarction, and death more than ASA at doses 650 and 1300mg
- the ACE trial remains the only randomized, double-blind trial of perioperative antiplatelet therapy in patients undergoing CEA. Such a study is lacking for clopidogrel and ASA+dipiridamol
- patients receiving CLP tend to have more significant perioperative bleeding; however, DAPT is not a contraindication to surgery
- ASA 11.7%, CLP 20.4%, ASA+CLP 24.1% [Oldag, 2012)
Procedure and post-procedural care
- surgery can be performed under local (LA) or general anesthesia (GA)
- the choice of anesthesia does not affect the outcome (GALA trial)
- neuromonitoring (SSEP, TCD) is beneficial during GA
- the choice is based on the patient, surgeon, or anesthesiologist’s preference
- the incision and arteriotomy are longitudinal or transverse (eversion CEA)
- heparinisation is used before clamping the artery
- use a temporary shunt to maintain adequate blood flow to the brain in the following situations:
- impaired consciousness after carotid clamping / impaired neuromonitoring parameters during GA
- known contralateral ICA occlusion, poor collateral circulation
- patch x direct suture
- patches are reported to have a lower risk of restenosis [Malas, 2015]
- patches are less likely to be detectable by ultrasound postoperatively
- heparin is neutralized after surgery is completed
- the patient is transferred to the ICU for monitoring of vital signs
- ensure strict BP correction (<150/100mm Hg) to prevent hyperperfusion syndrome
- regularly monitor neurostatus and surgical wound (bleeding, infection, etc.)
Complications
- the risk of perioperative complications depends on the following:
- correct indication and timing of the procedure
- quality of preprocedural care (statins, antiplatelet therapy, optimal BP, etc.)
- the experience and skill of the surgical team and the level of postoperative care
- increased perioperative risk is associated with the following conditions:
- unstable neurological status (evolving or fluctuating lesions)
- manifestation of multiple vascular lesions
- occlusion of the contralateral ICA or CCA (RR 1.91)
- tandem intracranial stenosis (RR 1.56)
- intraluminal thrombus
- female sex, advanced age (RR 1.36 in patients over 75 years)
- coronary heart disease
- history of heart failure
- chronic pulmonary disease (most commonly obstructive disease)
- arterial hypertension (RR 1.82)
- atherosclerotic peripheral artery disease (PAD); RR 2.19
CEA-related complications |
I. Central and general |
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II. Peripheral |
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Restenosis
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Follow-up
- it is recommended to perform an ultrasound examination at 1, (3) and 6 months after surgery to detect early restenosis
- according to AHA/ASA 2014, routine follow-up is not necessary (cost-benefit)
- however, in clinical practice, annual ultrasound follow-up is quite common
- follow up in the vascular clinic with comprehensive secondary prevention (including risk factor management) is advisable