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Carotid endarterectomy is a surgical procedure used to correct carotid stenosis (narrowing of the carotid artery lumen by atheroma), used particularly when this causes medical problems, such as transient ischemic attacks (TIAs) or cerebrovascular accidents (CVAs, strokes). Endarterectomy is the removal of material on the inside (end-) of an artery. Angioplasty and stenting of the carotid artery are undergoing investigation as alternatives to carotid endarterectomy.
Procedure
The internal, common and external carotid arteries are clamped, the lumen of the internal carotid artery is opened, and the atheromatous plaque substance removed. The artery is closed, hemostasis achieved, and the overlying layers closed. Many surgeons lay a temporary shunt to ensure blood supply to the brain during the procedure. The procedure may be performed under general or local anaesthesia. The latter allows for direct monitoring of neurological status by intra-operative verbal contact and testing of grip strength. With general anaesthesia indirect methods of assessing cerebral perfusion must be used, such as electroencephalography (EEG), transcranial doppler analysis and carotid artery stump pressure monitoring. At present there is no good evidence to show any major difference in outcome between local and general anaesthesia.
Non-invasive procedures have been developed, by threading catheters through the femoral artery and up through the aorta, and then inflating a balloon to to dilate the carotid artery, with or without a wire-mesh shunt.
Contra-indications
The procedure cannot be performed in case of : -
Complete internal carotid artery obstruction (because the intraluminal thrombus then extends too far downstream, well into the intracranial portion of the artery, for endarterectomy to be successful).
Previous stroke on the ipsilateral side with heavy sequelae because there is no point in preventing what has already happened.
Patient deemed unfit for the operation by the anaesthesiologist.
Complications
About 3% of patients will suffer neurological complications as a result of the procedure. Hemorrhage of the wound bed is potentially life-threatening, as swelling of the neck due to hematoma could compress the trachea. Rarely, the hypoglossal nerve can be damaged during surgery. This is likely to result in fasiculations developing on the tongue and paralysis of the affected side: on sticking it out, the patients tongue will deviate toward the affected side.
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