[Abstract] Objective To investigate the clinical application value of external carotid endarterectomy in the prevention of cerebral ischemic “stroke”. Methods The clinical data of 42 patients who underwent this procedure were summarized, and the time of arterial blockade and the occurrence of postoperative complications were analyzed. The average time of carotid artery block was 16 min, which was significantly lower than that of the conventional procedure, and the postoperative complications were less. Conclusion External carotid endarterectomy has the advantages of short blocking time and low restenosis rate, but it requires a high level of operator proficiency and patient’s local condition. Zhao Zhiqing, Department of Vascular Surgery, Shanghai Changhai Hospital
[Keywords] Carotid artery, stenosis, endarterectomy, external reversal
Treatment of Local Stenosis of Internal Carotid Artery with Eversion Endarterectomy
Zhao Zhiqing, Jing Zaiping, Lu Qingsheng, et al. Department of Vascular Surgery ,Changhai Hospital,Shanghai 200433 China.
[Abstract] Objective To evaluate the clinical value of eversion endarterectomy in preventing the ischemic stroke of brain. methods The clamping time of The clamping time of carotid artery and the postoperative complications in 42 cases that received eversion endarterectomy were summarized. The average clamping time of carotid artery was 16 minutes, much less than that of the routine method. Conclusion Eversion endarterectomy is the technique with many virtues, such as short clamping time and less incidence of restenosis postoperatively. But the ideal results leans both to the operator’s skills and the anatomical conditions.
[Key Words] Carotid, Stenosis, Endarterectomy, Eversion
The majority of cerebrovascular accidents (nearly 60%) are associated with atherosclerotic lesions in the extracranial segment of the carotid artery, and carotid endarterectomy is one of the most important tools to address this problem. As this technique has matured, there have been many improvements in the specific surgical approach, from the traditional arteriotomy endarterectomy to the addition of patches and then to the external reversal carotid endarterectomy. In recent years, we have achieved good results in the treatment of limited internal carotid artery stenosis using external reversal carotid endarterectomy, which is reported as follows.
1 Data and methods
General data A total of 96 cases of carotid endarterectomy were completed between March 1999 and August 2003, of which 42 cases were treated with external carotid endarterectomy on 45 sides. This included 30 cases in men and 12 cases in women, aged 53-81 years, with a mean of 69 years. The etiology was atherosclerosis, and the lesions were located at the beginning of the internal carotid artery or the dilated carotid artery. The lesions ranged from 1.8 to 2.5 cm, and the degree of stenosis: 50% to 70% in 16 cases on 17 sides and more than 70% in 26 cases on 28 sides. Systemic conditions: combined hypertension in 21 cases, coronary artery disease in 11 cases, diabetes mellitus in 9 cases, and atherosclerotic occlusive disease of the lower limbs in 6 cases. Clinical symptoms: 38 patients had clinical manifestations of ischemia in the internal carotid artery system, including 26 cases of unfavorable unilateral limb movement, 12 cases of unilateral limb sensory abnormalities, 10 cases of blackness, 5 cases of speech impairment, 2 cases of sudden collapse, and 2 cases of previous history of cerebral infarction.
Imaging examination All patients underwent preoperative cranial CT, bilateral carotid ultrasound and MRA examination of the neck vessels. The results showed that there were 23 cases of lacunar cerebral infarction, 31 cases combined with severe stenosis of one vertebral artery and 28 cases combined with stenosis of the contralateral carotid artery, of which 6 cases had stenosis >70%, 9 cases had 50%-70% and 14 cases had <50%.
Anesthesia General anesthesia was used in 29 cases, and cervical plexus block was used in 16 cases, among which one patient underwent bilateral carotid reversal endarterectomy under cervical plexus block anesthesia at the same time.
Surgical method The head end of the operating table was elevated 15°~20°, with the head tilted 45° to the opposite side. After exposing the carotid system by separation, the nerves emanating from the carotid body were infiltrated with 1% lidocaine to prevent bradycardia during surgery. The internal carotid → external carotid → common carotid artery was blocked sequentially, with systemic heparinization prior to blockade. The internal carotid artery was cut obliquely along the lower edge of the plaque at the bifurcation, and the intima was removed by clamping the external and middle carotid membranes with non-invasive forceps and turning them upward to the intimal weakness. The resection edges and peeling surface were carefully trimmed to prevent residual debris. The internal carotid artery is restored and then anastomosed to the original incision. The external carotid → common carotid → internal carotid artery was opened sequentially, blood flow was restored, drainage was placed, and the wound was closed.
2 Results
The intraoperative carotid artery block time ranged from 11 to 23 min, with an average of 15.7 min. In three patients, the internal carotid artery was redundant after endarterectomy, and the redundant part was resected and then anastomosed. All patients were awakened in the operating room before returning to the ward. Postoperative performance: Almost all patients showed excitement and increased speech within 24 h after surgery, and then gradually returned to normal. There were 11 cases of postoperative hypertension, all of them were patients with preoperative combined intractable hypertension. There were 3 cases of postoperative local hematoma, with an incidence of 6.7%; 1 case of wound bleeding, which was stopped by compression; 1 case of hoarseness, which was not specially treated and resolved on its own after 3 weeks. There was no perioperative death.
The follow-up period ranged from 3 to 24 months, and 4 cases were lost, with a follow-up rate of 90.5%. All patients had significant changes in symptoms such as limb dysfunction and blackness. One case was found to have 70% restenosis of the anastomosis at 16 months of follow-up, and endoluminal stenting was performed. 6 months of follow-up have elapsed, and there is no symptom of cerebral insufficiency.
3 Discussion
The first successful carotid endarterectomy was performed by DeBakey in 1953 [1], and over the next 50 years, the procedure has evolved rapidly and is now the mainstay of treatment for carotid stenosis. The most used surgical approach for carotid stenosis is still the standard one, in which the wall is incised longitudinally along the carotid artery, the intima is removed and the incision is closed. The disadvantage of this procedure is that postoperative restenosis of the internal carotid artery occurs in up to 24% of cases [1], while the use of patches prolongs carotid artery blockade and increases the risk of complications, as well as increasing the financial burden on the patient or increasing trauma (using autologous venous patches).
Advantages of external reversal surgery External reversal carotid endarterectomy involves circumferential incision of the arterial wall near the bifurcation of the common carotid artery, external reversal of the epicardium, and removal of sclerotic plaque followed by in situ anastomosis. Since the anastomosis is in the expanded part of the carotid artery and is end-to-end, the probability of restenosis in the anastomosis is greatly reduced, generally 0.3%-1.9%, compared with 1.1%-6.9% reported by the same group for the conventional procedure [2, 3], and Katras et al [4] reported a restenosis rate of 1.7% after external reversal carotid endarterectomy after a mean follow-up of 23 months, compared with The restenosis rate was 9.3% (P < 0.05), a statistically significant difference. In addition, the operation surface of the episiotomy is smaller, and only the circumferential anastomosis of the vascular incision is sufficient, while the blocking time is greatly reduced. The shortest arterial blocking time of 6 min has been recorded in the operations of this procedure that the author has participated in abroad. The average blocking time of our cases was 15.7 min, and the blocking time of carotid artery reported by Cao et al [5] was 7.4~25.5 min for external reversal, while the blocking time of standard procedure was 10.1~28.3 min, and the blocking time of standard procedure reported by most domestic reports [6] was more than 30 min. Shah et al [7] summarized 2249 cases after carotid endarterectomy and reported that the incidence of surgery-related permanent brain damage occurred after external carotid endarterectomy was 0.8%, while the incidence of surgery-related permanent brain damage in the standard procedure in the same group was 2.3%, which was a significant difference, and the reasons for this were mostly related to the blocking time.
In the case of internal carotid artery torsion due to carotid atherosclerosis, an external reversal carotid endarterectomy can be used to correct the torsion by removing the redundant portion of the internal carotid artery at the same time as the endarterectomy, and the arterial torsion is also an important cause of inadequate distal blood supply.
Limitations of the external reversal procedure The external reversal procedure requires dissection of the carotid artery and is relatively difficult to perform with a carotid diverter tube. Therefore, the operator must be very skilled in order to shorten the arterial block time and reduce complications. Some authors believe that the endothelium of the common carotid artery should be removed as much as possible to expand the blood flow to the inflow tract. The author has a different opinion: the advantage of external reversal carotid endarterectomy is the short carotid artery blocking time, and this procedure needs to be minimized because of the difficulty of adding a carotid diversion tube, so unnecessary operations should be reduced. If the plaque continues into the common carotid artery, conventional carotid endarterectomy can be used. The external reversal procedure requires exposure of a longer segment of the internal carotid artery and is therefore also contraindicated in patients with a high carotid bifurcation or a short neck.
This procedure is not recommended for patients with thick intima in the distal internal carotid artery, because after ectasia, the residual intimal edge is often difficult to fix after removal of the plaque, and after recanalization, the blood flow will be shocked, which will easily cause a live valve or entrapment. This procedure is also contraindicated in other patients with internal carotid artery thrombosis and carotid myofibrillar dysplasia.
To reduce the perfusion damage to the brain, the patient’s head should be elevated and the blood pressure should be controlled appropriately when opening the internal carotid artery. If the wound exudates a lot after the operation, fisetin can be given to antagonize the effect of heparin to prevent the formation of hematoma in the neck. Because of the weakness of the distal internal carotid artery wall after endarterectomy, postoperative elevation of blood pressure may easily cause anastomotic tearing, resulting in neck hematoma or bleeding. Sometimes hematoma compression may result in thrombosis within the internal carotid artery.
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