complicated open carotid interventions
TRANSCRIPT
Complicated Open Carotid InterventionsJeffrey R. Rubin, MD, FACS
Professor and Chief Vascular and Endovascular Surgery
Wayne State University and Detroit Medical Center
Carotid Artery Disease
• Atherosclerosis• Fibromuscular Dysplasic• Coils and kinks• Aneurysm• Arteritis (inflammatory or radiation induced)
Carotid Plaque
• Smooth• Irregular• Ulcerated (small, large, multiple)
Risk of stroke, myocardial infarction or death must be <3% to benefit patient
• Carotid stenting• Carotid endarterectomy– Standard– Eversion
• With OR without patch
Primary Restenosis
Carotid artery restenosis following endarterectomy and stenting ranges
from 1-20% nationally
Primary Restenosis
• <2 Months => Technical Problems• <24 Months => Intimal Hyperplasia• >24 Months => Recurrence or Progression of
Disease
Primary Restenosis
• Hyperplastic => 65%• Complex/Heterogeneous => 18%• Complex w/Thrombus/ I/P Hemorrage => 17%
Primary Restenosis
• Asymptomatic => 74%
Redo CEA
Clinical Dilemma : Open vs. Stenting
Redo CEA
Open Redo Intervention
1.Neck hostility2.Location of lesion3.Overall patient health4.Skill level of surgeon
Evaluation
• CAROLTID DUPLEX SCANNING• High sensitivity, specificity, accuracy• Plaque Morphology• Areas of Involvement• Bifurcation
Evaluation
CTA with IV contrast
Evaluation
Angiography
Preoperative Evaluation
• Laryngoscopy• Head CT Scan ?• Control of hypertension
Redo CEA
Surgical Options
•Redo endarterectomy & patch angioplasty•Patch angioplasty alone•Resection and vein / Artery interposition grafting
Complications
• Hematoma• Myocardial ischemia• TIA / CVA• Restenosis
Complications
Cranial Nerve Injuries
•Hypoglossal•Vagus•Marginal mandibular•Superior Laryngeal•Glossopharyngeal•Spinal Accessory
Cranial Nerve Injuries
After RCEA = 13%
•80% Temporary (Recovery <30 days)•16% Prolonged (Recovery >30 days)•4% Permanent
Open Redo Endarterectomy
• Stroke => 0%• Myocardial infarction => 0.5% (1 of 192)• Death => 0%
Redo CEA
Incidence of cerebrovascular events after Carotid artery stenting for RCAD = 2.2%
National Cardiovascular Data Registry
Redo CEA
Incidence of cerebrovascular events after redocarotid artery open intervention = 0%
Redo CEA
• <1% First time CEA developed significant recurrence
• 1.5% RCEA’s developed significant recurrence (others => 4.6^ - 11%)