Technical Adjuncts in High Risk Patients Undergoing

Endarterectomy

Joseph P. Archie Jr.

Risk Factors

• Systemic Co-morbidity (cardiac, pulmonary)• Combined CEA-CAB• Contralateral Internal Carotid Occlusion• Hostile Neck - Prior Irradiation, Prior CEA• High Internal Carotid Lesion

Cardio-Pulmonary Risk Technical Adjuncts

• Bradycardia - carotid sinus, vagal

Block carotid sinus with xylocain

Give atropine

Combined CEA - CABTechnical Adjuncts

• Combined risk = CEA risk + CAB risk

• Prep & drape for combined operations

• CEA done while vein harvested

• Saphenous vein patch

• Drain

• Added time about 45 minutes

Contralateral ICA Occlusion

• NASCET 6/43 (14 %) stroke or death, versus 86/737 (6 %), P = 0.84

• ASAC 2/86 (2 %) stroke, versus 17/737 (2 %)

• Pooled stroke rate for 8 studies 1992-2001 26/592 (4.4%) versus 87/3,392 (2.3%)P = 0.013

Contralateral ICA OcclusionTechnical Adjunct

• SHUNT - SHUNT - SHUNT

• Approximately 50 % of patients with contralateral occlusion meet selective shunt criteria

Prior Irradiated NeckTechnical Adjuncts

• Cranial nerve protection - nerve stimulator

• Carotid exposure - friable internal carotid

• Autologous vein patch or bypass

Prior CEA

• Pooled outcomes from 10 studies 1995 to 2001

Stroke 24/847 (2.8 %)

Death 6/847 (0.7%)

Prior CEATechnical Adjuncts

• Old operative note

• Expose common carotid proximal to and internal carotid distal to prior dissection (CW Doppler probe)

• Nerve stimulator

• Patch or bypass (outcomes similar)

• Material: vein and synthetics have similar outcomes for both patch and bypass