Carotid Endarterectomy: Current Concepts and Practice Patterns

Abstract

Background Stroke is the number one cause of disability and third leading cause of death among adults in the United States. A major cause of stroke is carotid artery stenosis (CAS) caused by atherosclerotic plaques. Randomized trials have varying results regarding the equivalence and perioperative complication rates of stents versus carotid endarterectomy (CEA) in the management of CAS. Objectives We review the evidence for the current management of CAS and describe the current concepts and practice patterns of CEA. Methods A literature search was conducted using PubMed to identify relevant studies regarding CEA and stenting for the management of CAS. Results The introduction of CAS has led to a decrease in the percentage of CEA and an increase in the number of CAS procedures performed in the context of all revascularization procedures. However, the efficacy of stents in patients with symptomatic CAS remains unclear because of varying results among randomized trials, but the perioperative complication rates exceed those found after CEA. Conclusions Vascular surgeons are uniquely positioned to treat carotid artery disease through medical therapy, CEA, and stenting. Although data from randomized trials differ, it is important for surgeons to make clinical decisions based on the patient. We believe that CAS can be adopted with low complication rate in a selected subgroup of patients, but CEA should remain the standard of care. This current evidence should be incorporated into practice of the modern vascular surgeon.

Impact of Carotid Endarterectomy on Choroidal Thickness and Volume in Enhanced Depth Optical Coherence Tomography Imaging

“…Significantly, the young age of our study participants may provide some explanation. Carotid endarterectomy is considered an effective method for reducing brain stroke risk in patients with severe ICAS [32,33]. Numerous studies have shown its beneficial effect on blood flow in the ophthalmic artery, central retinal artery, posterior ciliary arteries, and chorioretinal circulation using Doppler ultrasonography and laser speckle flowgraphy [21,22,26].…”

Phenomenology of neurophysiologic changes during surgical treatment of carotid stenosis using signal analysis

“…However, although we are able to show that there are changes in some of these parameters we are not able to determine the clinical significance of these parameters in this preliminary study. The study also showed that using these parameters there was a difference between the two approaches to the treatment of carotid stenosis, ( Saha et al, 2015 ).…”

“…Despite the adaptability of the brain, there is still a 2.1% risk of peri-operative major stroke and death with endarterectomy from either a hypoperfusion or embolic etiology, ( Ferguson et al, 1999 ). During the endovascular procedure there is no equivalent of clamping, although there may often be a period of angioplasty which for a brief period of time does occlude the blood supply to the brain, ( Saha et al, 2015 ). In many centres a device is deployed distal to the stent to capture any emboli dislodged during the deployment of the stent or angioplasty.…”

Increased serum level of high sensitivity troponin T even prior to surgery can predict adverse events during carotid endarterectomy

“…Awake carotid endarterectomy (CEA) under regional anesthesia (RA) is a challenging procedure as it is often associated with increased peri-operative stress. 1,2 The stress response to CEA is generally abolished within 24 h. 2,3 Elevated systemic cortisol level reflecting intraoperative stress response, directly correlates with cerebral hypoperfusion during carotid artery cross-clamping. 3 Therefore, attenuation of the stress response to CEA might decrease the incidence of cerebral ischemic events.…”