Download - Complicated Open Carotid Interventions
![Page 1: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/1.jpg)
Complicated Open Carotid InterventionsJeffrey R. Rubin, MD, FACS
Professor and Chief Vascular and Endovascular Surgery
Wayne State University and Detroit Medical Center
![Page 2: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/2.jpg)
Carotid Artery Disease
• Atherosclerosis• Fibromuscular Dysplasic• Coils and kinks• Aneurysm• Arteritis (inflammatory or radiation induced)
![Page 3: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/3.jpg)
![Page 4: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/4.jpg)
![Page 5: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/5.jpg)
![Page 6: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/6.jpg)
![Page 7: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/7.jpg)
Carotid Plaque
• Smooth• Irregular• Ulcerated (small, large, multiple)
![Page 8: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/8.jpg)
![Page 9: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/9.jpg)
![Page 10: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/10.jpg)
![Page 11: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/11.jpg)
Risk of stroke, myocardial infarction or death must be <3% to benefit patient
![Page 12: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/12.jpg)
• Carotid stenting• Carotid endarterectomy– Standard– Eversion
• With OR without patch
![Page 13: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/13.jpg)
![Page 14: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/14.jpg)
![Page 15: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/15.jpg)
Primary Restenosis
Carotid artery restenosis following endarterectomy and stenting ranges
from 1-20% nationally
![Page 16: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/16.jpg)
Primary Restenosis
• <2 Months => Technical Problems• <24 Months => Intimal Hyperplasia• >24 Months => Recurrence or Progression of
Disease
![Page 17: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/17.jpg)
Primary Restenosis
• Hyperplastic => 65%• Complex/Heterogeneous => 18%• Complex w/Thrombus/ I/P Hemorrage => 17%
![Page 18: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/18.jpg)
Primary Restenosis
• Asymptomatic => 74%
![Page 19: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/19.jpg)
Redo CEA
Clinical Dilemma : Open vs. Stenting
![Page 20: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/20.jpg)
Redo CEA
Open Redo Intervention
1.Neck hostility2.Location of lesion3.Overall patient health4.Skill level of surgeon
![Page 21: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/21.jpg)
Evaluation
• CAROLTID DUPLEX SCANNING• High sensitivity, specificity, accuracy• Plaque Morphology• Areas of Involvement• Bifurcation
![Page 22: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/22.jpg)
Evaluation
CTA with IV contrast
![Page 23: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/23.jpg)
Evaluation
Angiography
![Page 24: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/24.jpg)
![Page 25: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/25.jpg)
Preoperative Evaluation
• Laryngoscopy• Head CT Scan ?• Control of hypertension
![Page 26: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/26.jpg)
Redo CEA
Surgical Options
•Redo endarterectomy & patch angioplasty•Patch angioplasty alone•Resection and vein / Artery interposition grafting
![Page 27: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/27.jpg)
![Page 28: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/28.jpg)
![Page 29: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/29.jpg)
![Page 30: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/30.jpg)
![Page 31: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/31.jpg)
Complications
• Hematoma• Myocardial ischemia• TIA / CVA• Restenosis
![Page 32: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/32.jpg)
Complications
Cranial Nerve Injuries
•Hypoglossal•Vagus•Marginal mandibular•Superior Laryngeal•Glossopharyngeal•Spinal Accessory
![Page 33: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/33.jpg)
Cranial Nerve Injuries
After RCEA = 13%
•80% Temporary (Recovery <30 days)•16% Prolonged (Recovery >30 days)•4% Permanent
![Page 34: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/34.jpg)
Open Redo Endarterectomy
• Stroke => 0%• Myocardial infarction => 0.5% (1 of 192)• Death => 0%
![Page 35: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/35.jpg)
Redo CEA
Incidence of cerebrovascular events after Carotid artery stenting for RCAD = 2.2%
National Cardiovascular Data Registry
![Page 36: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/36.jpg)
Redo CEA
Incidence of cerebrovascular events after redocarotid artery open intervention = 0%
![Page 37: Complicated Open Carotid Interventions](https://reader035.vdocument.in/reader035/viewer/2022070516/5874e6331a28ab917a8b4d31/html5/thumbnails/37.jpg)
Redo CEA
• <1% First time CEA developed significant recurrence
• 1.5% RCEA’s developed significant recurrence (others => 4.6^ - 11%)