1. CAROTID ARTERY ENDARTHERECTOMY &INTERVENTION
Presented By:
Modaghegh M.D. (Vascular Surgeon)
Mashhad Vascular Surgery Department
MUMS

2. PRACTICE GUIDELINES 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/
SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the
Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive Summary
American Stroke Association
Society for Vascular Surgery

3. Symptomatic Patients ECST and NASCET )1991(
TIA or mild stroke and 30% to 99% ipsilateral carotid stenosis
CEA and medical management Vs medical therapy alone
The trial was stopped after 18 months of follow-up for patients with 70% to 99% stenosis because of a significant benefit with CEA
(cumulative ipsilateral stroke risk, including perioperative stroke, was 9% at 2 years for the CEA group versus 26% with medical therapy alone). Over 5 years, the rate of ipsilateral stroke, including perioperative events, was 15.7% with CEA compared with 22% for medically managed patients
Symptomatic Patients

4. Results of the ECST and NASCET
In ECST, surgery was highly beneficial for 70% to 99% stenosis and moderately beneficial for 50% to 69% stenosis and of little benefit in patients with carotid near occlusion .
[Stroke. 2003;34: ]

5. Asymptomatic Patients
ACAS
CEA plus aspirin compared with aspirin without surgery.
The trial was stopped after an advantage to CEA became apparent
among patients with 60% stenosis
(Projected 5-year rates of ipsilateral stroke, perioperative stroke, and death were 5.1% for surgical patients and 11% for patients treated medically.)
Asymptomatic Patients

6. Overview of the Asymptomatic Carotid Atherosclerosis Study (ACAS).
patients with asymptomatic stenosis of 60% or greater to either carotid endarterectomy and aspirin or aspirin alone.
Study was interrupted because of a significant benefit identified in patients undergoing carotid endarterectomy. [JAMA 273: 1421, 1995.]

7. Asymptomatic Patients
ACST
immediate versus delayed CEA
3.1% 30-day risk of stroke or death in either group,
Five-year rates were 6.4% for the early-surgery group versus 11.7% for the group initially managed medically
The benefit of surgery today may be less than in the early trials, and the 3% complication rate should be interpreted in the context of advances in medical therapy.
Asymptomatic Patients

8. Carotid Endarterectomy
THE GOLD STANDARD FOR SYMPTOMATIC AND ASYMPTOMATIC PATIENTS WITH CAROTID ARTERY STENOSIS

9. CONTRA INDICATIONS FOR CAROTID ENDARTHERECTOMY

10. Contra indications Short life expectancy
Rutherford 2006
Acute major stroke without improvement
Previous major stroke with
decreased consciousness or
worsening of Neurologic symptoms
Vertebrobasilar TIA
Multi infarct dementia
Sabiston 2007
Severe neurologic difficulties
Large infarction
Intra cranial hemorrhage

11. CEA

12. Monitoring for the need of carotid shunt
Awake patients
EEG
Stump pressure
Cerebral oximetry

13. Protection Coronary stenting or combined operation
Serious heart problem
Acceptable tolerance
Intact Willis circle
Cervical block
Acceptable patency of other vessels
Serious medical problems
Cervical block
to avoid of BP fluctuation
Low cardiac compliance
Old age

14. Cervical Block

15. Position

16. Quality of anesthesia by CB

17. Quality of anesthesia by CB

18. Administration of Manitol
Protection
Shunt
General Anesthesia
O2 100%
Increase of BP
Dexamethason
Clamping
Heparin
Operation completed
Administration of Manitol

19. Protection Before sinus stimulation 1 cc Lidocain Foley catheter
During surgery
NG or Dopamine for
Control of hypertension
or hypotension
Administration of Aspirin before, during and after of surgery

20. Anatomy Carotid body tumor Vagus nerve Carotid bifurcation
Hypoglossal nerve
Jugular vein
SCM

21. Shunt

22. Plaque during surgery

23. Plaque Resection

24. Plaque Resection

25. Complete Obstruction

26. Repair of Artery

27. CEA Vs CAS The EVA-3S (Endarterectomy Versus Angioplasty in Patients
with Symptomatic Severe Carotid Stenosis)
within 120 days of TIA or stroke + 60% stenosis
outcome was stroke or death within 30 days
Enrollment stopped in 2005, with 520 patients enrolled, because of higher 30-day rates of stroke and adverse events in the CAS arm.
CEA Vs CAS

28. Table 7. Summary of Recommendations Regarding the Selection of Revascularization Techniques for Patients With Carotid Artery Stenosis
Symptomatic Patients
Asymptomatic
Patients
50% to 69%
Stenosis
70% to 99%
Stenosis*
Endarterectomy
Class I
Class IIa
LOE: B
LOE: A
Stenting
Class IIb

29. ICSS: Stroke severity by treatment allocation
End point
CAS
CEA
Fatal stroke 9 2
Disabling stroke 17 19
Nondisabling stroke 39 14
End point
CAS, n (%)
CEA, n (%)
Hazard ratio (95% CI)
New ischemic lesions
50 (46.3)
13 (14.1)
5.24
(2.61–10.53)
CAS=carotid artery stenting
CEA=carotid endarterectomy
Brown MM et al. European Stroke Conference 2009; May 27, 2009; Stockholm, Sweden. 29

30. Symptomatic patients have a higher
risk than asymptomatic patients (OR 1.62; p0.0001), as do those with hemispheric versus retinal symptoms (OR 2.31; p0.001), urgent versus nonurgent operation (OR 4.9; p0.001), and reoperation versus primary surgery (OR 1.95; p0.018)

31. Cerebral Protection Devices For CAS:
Distal occlusion balloon
Distal filter
Proximal protection with flow stasis or reversal

32. Distal occlusion balloon

33. :Distal filters

40. 40

43. Proximal protection with flow stasis (Mo.Ma system)

48. Proximal protection with flow reversal: (Reverse flow to femoral vein)
Gore Flow Reversal System
MICHI Neuroprotection System

49. Thanks for your attention