Fig. 28.1
Standard carotid endarterectomy (Adapted from Zarins and Gewertz [3]. With permission from Elsevier)
The sCEA technique is ubiquitous, being utilized in the majority of the more than 100,000 CEA procedures performed annually [4]. It was the primary technique employed by investigators demonstrating the efficacy of the procedure in multicenter randomized trials [5, 6]. The contemporary clinical results of CEA are, perhaps, best illustrated by the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) trial which randomized 2502 patients with carotid stenosis to undergo either CEA or carotid artery stenting in 117 North American centers [7]. Although the use of the sCEA wasn’t mandatory, the fact that 62 % of patients underwent patch angioplasty suggests that it was the dominant technique. For the 1240 patients undergoing CEA in the trial, the overall risks of death, major ipsilateral stroke and any stroke were 0.3 %, 0.3 % and 2.3 %, respectively. It’s instructive to note that the overall incidence of periprocedural stroke in patients undergoing primary CEA (2.3 %) was statistically significantly lower than in patients undergoing primary stenting (4.1 %; p = 0.01).
Proponents of the sCEA technique point to its proven clinical utility and the fundamental surgical advantage of direct visualization of the distal extent of the plaque. Other potential benefits include the relative ease of intraluminal shunt insertion, the option to provide enhanced luminal size through the use of patch angioplasty, the avoidance of circumferential dissection with minimal disturbance of the carotid baroreceptors, and the efficiency with which the procedure can be taught to surgical trainees.
The technical success of sCEA technique depends, in some measure, upon successful eversion endarterectomy of the ECA. Indeed, the ease of ECA eversion was likely the stimulus for the rise in popularity of the alternative technique: eversion CEA (eCEA).
Eversion Carotid Endarterectomy (eCEA)
ECEA was originally described by Michael DeBakey in his classic clinical review of extracardiac vascular surgery published in 1959 [8–10]. It is performed via a similar incision as sCEA, although some would argue that eCEA requires only a limited operative field and can be performed through a smaller incision. Surgical exposure of the carotid bifurcation proceeds identically to sCEA, except that the arteries should be freed from the surrounding tissues circumferentially, and division of the superior thyroid artery should be performed as a matter of routine.
Once the arteries have been exposed and clamped, the CCA is transected just proximal to the bifurcation. Figure 28.2 depicts a CCA that is transected transversely, although many authors recommend oblique transection as a means to facilitate visualization and closure. Following division of the CCA, endarterectomy of the ICA and ECA is performed by developing a cleavage plane within the arterial media and everting it over the plaque (Fig. 28.2b). The plaque acts as a natural mandrill over which to fold the artery; it is gently retracted caudad to facilitate the dissection. Eversion CEA of the ECA is performed in an identical fashion as in sCEA. Because primary carotid plaques are localized to the bulb and proximal ICA, downward retraction and careful blunt withdrawal of the plaque will cause it to “pop” out of the ICA once it reaches its natural endpoint. The result is complete excision of the plaque from the both the ECA and ICA with achievement of a smooth residual lumens that contain no suture lines (Fig. 28.2c).
Fig. 28.2
Eversion carotid endarterectomy (Adapted from Black et al. [11]. With permission from Elsevier)
Attention is then turned toward the CCA which is everted in a similar fashion through, theoretically, the same cleavage plane. There’s rarely a natural proximal endpoint of the plaque within the CCA so it’s transected sharply after a distance of approximately 2 cm. If the ICA is redundant, a rim of CCA can be resected to accomplish its straightening. End-to-end anastomosis of the two ends of the transected CCA is facilitated by rotating the “freely floating” artery within the field (Fig. 28.2e). The completed reconstruction bears no suture line within the ICA (Fig. 28.2f). In the 1990s, several surgeons described modifications to the above technique, most notably Vanmaele et al. who proposed transection, eversion and reimplantation of the ICA at its origin [12], and Reigner et al. who described oblique transaction of the ICA distal to the lesion followed by eCEA through longitudinal incision of the CCA and ECA [13].
Proponents of the eCEA technique point to the more limited dissection it requires, the rapidity in which it can be performed, the ease to which arterial redundancy can be addressed, the advantages of placing sutures in the widest part of the bifurcation, the avoidance of patches leading to better fluid dynamics [14], the fact that the reconstruction is accomplished without tacking stitches or suture lines in the ICA [15, 16] and, potentially, reduced restenosis [17]. Some even advocate the procedure for recurrent stenoses [18, 19].
Search Strategy
A search of the University of Chicago Articles Plus + database was conducted for the years 1997–2015 to identify published data regarding open surgical approaches to treat carotid artery disease using the PICO outline (Table 28.1). The University of Chicago Articles Plus + is a database and search tool that allows simultaneous searching of a broad range of articles, books, and other collections. An Articles Plus + search includes hundreds of the Library’s article databases, including MEDLINE, Science Direct and Academic Search Premier, over 40,000 journals and periodicals, the University of Chicago library catalog, and digitized collections of documents and images from a variety of organizations.
Table 28.1
PICO table for technical approach to CEA
P (patients) | I (intervention) | C (comparator group) | O (outcomes measured) |
|---|---|---|---|
Patients undergoing carotid endarterectomy | Standard carotid endarterectomy | Eversion carotid endarterectomy | Restenosis Stroke Death |
Eight comparative trials, and four single arm studies, were included in the analysis (see Tables 28.2 and 28.3).
Table 28.2
Large single-arm series of eCEA
Author and Reference | Year | n (CEAs) | Sympto-matic (%) | Shunt use (%) | Mean cross-clamp time (min) | Cranial/cervical nerve injury (%) | Reexploration for hemorrhage (%) | Peri-operative stroke/death (%) | Median follow-up (years) | Restenosis (%) | Late ipsilateral stroke (%) |
|---|---|---|---|---|---|---|---|---|---|---|---|
Ballotta et al. [20] | 2014 | 1773 | 72 % | 16 % | NR | 4.5 % | 4.3 % | 0.4 % | 11.2 | 0.5 % | 0.5 % |
Ballotta and Giau [21] | 2003 | 624 | 64 % | 7 % | NR | 0.5 % | 0.0 % | 0.6 % | 4.3 | 0.0 % | 0.0 % |
Black et al. [11] | 2011 | 534 | 44 % | 0 % | 18 | 0.9 % | 0.6 % | 3.8 % | 8.9 | 4.1 % | NR |
Radak et al. [22] | 2012 | 9897 | 98 % | 0 % | 12 | 0.8 % | 1.7 % | NR | NR | 4.3 % | NR |
Weighted Average | 90 % | 2.6 % | 1.3 % | 1.9 % | 1.1 % | 3.6 % | 0.3 % |
Table 28.3
Large comparative series of sCEA and eCEA
Author and reference | Year | n (CEAs) | Symptomatic (%) | Shunt use (%) | Mean cross-clamp time (min) | Cranial/cervical nerve injury (%) | Reexploration for hemorrhage (%) | Peri-operative stroke/death (%) | Median follow-up (years) | Restenosis (%) | Late ipsilateral stroke (%) | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
sCEA | eCEA | sCEA | eCEA | sCEA | eCEA | sCEA | eCEA | sCEA | eCEA | sCEA | eCEA | sCEA | eCEA | sCEA | eCEA | sCEA | eCEA | |||
Brothers [23] | 2005 | 100 | 100 | 40 % | 37 % | 59 % | 87 % | NR | NR | NR | NR | NR | NR | 3.0 %
 Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
Get Clinical Tree app for offline access
| ||||||