Carotid endarterectomy CEA
Mild stenosis: <30%
Moderate stenosis: 30%-69%
Severe stenosis: 70%-99%
Complications of the procedure included respiratory impairment (5%), cerebral nerve injury, hematoma in the operative area (5%), myocardial infarction (2%), and pulmonary embolism (1%). The preventive effect of carotid endarterectomy for multiple ischemic strokes was confirmed.
The rate of surgical disability and death must be <6% to benefit from carotid endarterectomy.
All patients take aspirin, 325 mg/d
Male patients may benefit more from the procedure. Perhaps this is related to the fact that female patients have thinner arteries, which are more difficult to manipulate and have higher postoperative complications (3.6% vs. 1.7% in men).
According to the size shown by carotid angiography, ulcers are classified as type A less than 10 mm2 , type B 10-40 mm2
Type C exceeds 40 mm. The annual stroke rate for type C ulcers themselves is 7.5%, and type A ulcers do not increase the incidence of stroke.
asymptomatic patients with carotid stenosis ≥ 60%, surgery is clearly beneficial.
Stroke classification.
Mild stroke: neurological signs and symptoms after stroke, but no significant functional impairment
Moderate stroke: complete loss of one aspect, e.g., single limb, language function, but other functions are largely preserved and life is self-care.
Severe stroke: unable to take care of himself/herself
Carotid stenosis with a history of coronary artery disease is quite common, and 50-60% have significant coronary artery disease.
Myocardial infarction is the cause of 25%-50% of perioperative deaths and 70% of late deaths.
Assessment of the cardiac condition is important in patients with carotid stenosis, especially in those who are proposed for surgery.
An electrocardiogram is a mandatory routine test to screen for possible prior myocardial infarction with conduction block.
The sensitivity and specificity of exercise ECG for the diagnosis of occlusive coronary artery disease is 68% and 77%, respectively.
Carotid ultrasound is often used as the preferred noninvasive test.
Gray-scale ultrasound; pulsed Doppler; color Doppler
Intraplaque hemorrhage makes the plaque echogenically inhomogeneous and is an important sign of unstable plaque.
The diagnostic agreement rate between carotid ultrasonography and DSA is as high as 90%, and the accuracy rate of determining the tissue characteristics of plaque is 88.2%.
MRA has high sensitivity and specificity for atherosclerotic stenosis of carotid arteries.
Hyperperfusion syndrome occurs in 11.6%
To raise the mean arterial pressure, the dose of inhaled anesthetics can be reduced first. Boosting agents such as dobutamine or phenylephrine (neofulvin) can be applied, and the application of boosting agents may lead to myocardial ischemia.
The best anesthetic drug is isoproterenol (propofol), which can reduce the cerebral metabolic rate CMR, and the inhalation anesthetic drug is isoflurane, which can also reduce CMR.
Intravenous administration of heparin 5000u
1-2 ml of 1% lidocaine is injected with a fine needle under the epicardium of the bifurcation to close the carotid sinus.
It is almost impossible to completely remove the plaque from the CCA. The easiest to separate and remove is the brittle and soft, plaque with hemorrhage and thrombus in it, the
6-0prolene wire. vicryl by Ethicon
Heparin 60-80u/kg intravenously before temporary carotid artery block, supplemented with 1000-2000u/h if the block is longer than 1h, and dextran-40 500ml at the beginning of the procedure, followed by a continuation of 500-1000ml intravenously over 24 hours.
Pruitt-inahara external type/inahara-pruitt internal type shunt with a maximum filling volume of vy 0.25 ml of distal balloon and 1.25-1.5 ml proximal.
Restenosis is more often seen in women and smokers
Heparin increases the activity of antithrombin by 1000 times, indirectly blocks the clotting chain, inhibits platelet activation, thromboxane release and platelet adhesion to collagen, and has an anti-inflammatory effect.
The average dose of 5000u is administered intravenously and waited for 4min after heparin is distributed to the whole body before blocking the carotid artery.
1mg of fisetin can neutralize 100u of heparin, and the half-life of heparin is 90min.
Carotid stenosis has a protective effect on its distal aneurysm.
Carotid endarterectomy does not increase the risk of asymptomatic aneurysm rupture, .
The age of 65 years or older is defined as the elderly population, young-old: 65-74 years; old-old: 75-84 years; old-old-old: 85 years or older. 7% of people over 65 years of age have strokes.
The incidence of stroke is higher in those with total serum cholesterol >8mmol/l.
Lipid-lowering drugs: Statin (statins), first-line drugs, simvastatin, pravastatin.
If LDL cholesterol >3.38 mmol/l, statin should be taken after surgery.
All patients after carotid endarterectomy should quit smoking.
Cerebral ischemia is the most significant complication of carotid endarterectomy, and dislodgement of the embolus during dissection and separation of the carotid artery is probably the most common cause of intraoperative embolism.
Almost 2/3 of carotid endarterectomy patients have mild headache.
The majority (75%) of cerebral hemorrhages occur within 2-5 days postoperatively, and convulsions are localized motor episodes. 40% of patients with convulsive episodes will have cerebral hemorrhage, and the morbidity and mortality rate is as high as 50% once the hemorrhage occurs.
Transcranial Doppler ultrasound is the most commonly used bedside exam. Hyperperfused patients show accelerated mean blood flow in the middle cerebral artery on the side of surgery.
The incidence of perioperative myocardial infarction during carotid endarterectomy is 1.5%-5%.
Carotid sinus nerve Hering nerve.
The incidence of lipid in the operative area is 3-5%
thrombotic occlusion occurs mostly 20 min to 4 hours after surgery and does not exceed 6-8 hours.
Most patients with restenosis are asymptomatic.
Sundt classification of CEA patients
Grade I: neurologically stable, no significant systemic or angiographically confirmed risk factors, unilateral or bilateral carotid stenosis.
Grade II: neurologically stable, no significant systemic risk factors, but with angiographically confirmed significant risk factors.
Grade III: Stable neurological condition with significant systemic risk factors, with or without angiographically confirmed significant risk factors.
Grade IV: Unstable neurological condition with or without significant risk factors confirmed by systemic or angiography.
Grade V: Acute carotid artery occlusion.
Grade VI: Recurrence of stenosis after carotid endarterectomy with symptoms.