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Vascular Surgery for Carotid Disease

Carotid endarterectomy to prevent Stroke

CEA is for those with anterior circulation TIA or non disabling anterior circulation stroke and should be done on those with a symptomatic stenosis of > 70%. The doppler will show high velocities which generate turbulence and embolic stroke disease. The atherosclerotic stenosing plaque can also become unstable and cause total occlusion. There is nothing to be done once the vessel is totally occluded as the damage is done. It is surprising that patients can have asymptomatic complete occlusion of one or other carotid. The surgery should be done within days but definitely less than 2 weeks. Treat as a vascular emergency. Surgical expertise and general surgical care are important. Carotid angioplasty and stenting is much talked about as an alternative to CEA but current evidence has not shown it to be superior to CEA and possibly to have higher complications.

Secondary prevention of stroke with carotid surgery

Severity of stenosisRelative risk reduction Absolute risk reductionNumber-needed-to-operate to prevent one stroke in 2 years
OccludedNot for SurgeryNot for SurgeryNot for Surgery
Symptomatic (70-99%)65%13%8%
Symptomatic (50-69%)30%7%14%
Symptomatic (< 50%)No benefitNo benefitNo benefit

There is some benefit of surgery for 50-70% stenosis, except in women and those with ocular events. The benefit of surgery is modest in patients with ocular events, lacunar infarcts, contralateral carotid occlusion, and with collapse of the vessel distal to very severe stenosis. The benefit of surgery is greatest within days of the relevant cerebrovascular event and declines rapidly over time, so that it is minimal after 3-6 months. There is little benefit for surgery in patients with asymptomatic carotid stenosis

Complications

  • Stroke: there is a chance that surgery can lead to thrombus in situ around the area of the surgery and ipsilateral stroke.
  • Reperfusion syndrome: Relief of stenosis can cause a hyperfusion syndrome with oedema on the ipsilateral affected side and this can precipitate weakness and a stroke like presentation.

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