ISCHEMIC STROKE / PREVENTION

Carotid endarterectomy (CEA)

Created 31/01/2023, last revision 01/03/2023

  • CEA is the gold standard for the management of significant carotid stenosis (both symptomatic and asymptomatic)
    • randomized trials have confirmed the effect of CEA compared to conservative treatment:
  • 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
Carotid endarterectomy (CEA)

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)
    • ICA occlusion with retrograde filling of the siphon on angiography is more likely to be recanalized with CEA   Occlusion of extracranial ICA with retrograde filling of distal segments

Symptomatic carotid stenosis

Content available only for logged-in subscribers (registration will be available soon)

Asymptomatic carotid stenosis

→ see separate chapter

Symptomatic carotid stenosis – specific situations

Content available only for logged-in subscribers (registration will be available soon)

Timing

Content available only for logged-in subscribers (registration will be available soon)

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

Carotid artery stenosis (ultrasound, CTA, MRA, DSA)
  • 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)

Antiplatelet therapy and CEA

  • 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

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.)
Longitudinal CEA
Eversion CEA
CEA with shunt

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
  • hemodynamic instability
    • heart failure due to myocardial infarction
    • hypotension due to baroreceptor dysfunction (duration < 48h, more common after CAS) or arrhythmia
  • ischemic stroke
    • distal embolization
    • hypoperfusion caused by carotid clamping
    • acute carotid thrombosis
  • hyperperfusion syndrome (within up to 2 weeks after surgery) manifested by:
    • brain edema
    • ICH and/or SAH
 II. Peripheral
  • hematoma in the surgical field (may lead to airway compression)
  • cranial nerve paresis
  • wound infection
Content available only for logged-in subscribers (registration will be available soon)

Restenosis

Content available only for logged-in subscribers (registration will be available soon)

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

Related Content

Send this to a friend
Hi,
you may find this topic useful:

Carotid endarterectomy (CEA)
link: https://www.stroke-manual.com/carotid-endarterectomy-cea/