Practical Techniques of Carotid Endarterectomy

Description:

This book addresses multiple principles of carotid endarterectomy in terms of cervical anatomy, surgical techniques, practical cases and frequent questions stemming from clinical practice. Carotid endarterectomy (CEA) is an effective way to the treatment of carotid artery stenosis, which significantly reduce the risk of stroke. This book covers the key concepts and common question in CEA. It is a practical book focusing on basic surgical technical techniques, but not covers controversial issues.

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Preface

Carotid endarterectomy was first performed on patients in 1953 by Professor DeBakey in vascular surgery and has been performed for more than 60 years. It has become an important routine procedure in neurosurgery and vascular surgery because of its effectiveness in treating carotid stenosis and reducing the patient’s risk of developing stroke. This book is based on a case-by-case discussion, in which the indications, principles and technical points of carotid endarterectomy are revealed step by step through the analysis of each patient’s specific case, and the specific discussion of each case is based on clinical practice, while the views of other experts are integrated, which is believed to be beneficial for beginners. The book is a practical, illustrated reference that can be used as a reference for the beginner or as a flexible tool for the skilled practitioner.

Ischemic stroke caused by carotid stenosis has become a highly prevalent disease in today’s society. Carotid endarterectomy (CEA) has become an important routine procedure in neurosurgery and vascular surgery, as it can effectively treat carotid artery stenosis and reduce the risk of stroke. For beginners, although they understand the procedure, there is still some confusion in the actual operation. The reason for this is that the beginner is not clear enough about the detailed instructions of the surgical steps, while still being vague about many concepts. For example, when positioning the patient, how many degrees to rotate the head and how many degrees to pad the shoulders; when incising the vessel wall, how long should the vessel be cut and should the incision line be located on the inner side of the vessel wall or outside; what is the stitch distance and margin distance for the needle entry when suturing the vessel wall …… such and such details. When all these issues are clear, the procedure can be carried out as smoothly as if guided by a navigation system.

Since 2001, I started to study with Professor Xiang’en Shi. In the past 20 years, the deepest impression that Professor Shi has given me is his rigorous and down-to-earth approach, his meticulous approach to his work, and his strict requirements for the young surgeons. This book records the problems and solutions encountered by the author as a beginner in the learning process, as well as the typical questions and answers raised by the trainees as beginners in the course of many carotid endarterectomy study sessions held by the authors. The book is practical and relatively superficial, and certain currently controversial issues are not discussed in depth. We hope to demonstrate the important principles and technical points of CEA by dissecting the problems that the author has personally experienced. Beginners should always follow the important principles of surgery and should not do as they please. This book can be used as a reference for beginners when they encounter problems. However, when they become skilled in the technique, they can be flexible and adaptable. They can achieve the highest state of “there is no definite principles, only the change is the principle”.

We welcome all readers to share actively without hesitation.

Los Angeles, USA Hai Qian

Table of contents :
Preface
Preface
Contents
Basics
1 What Is CEA
2 Measurement of Carotid Stenosis and Surgical Indications
2.1 Carotid Stenosis Measurement
2.2 Surgical Indications and Factor-Related Complications
2.2.1 Surgical Indications of CEA
2.2.2 High Risk Factors of CEA
2.2.3 Microsurgical Anatomy of CEA
3 Simplified Criterion of CEA Indication
4 MRI and Surgical Timing
5 Ultrasound Doppler and Angiography Workup
6 Bilateral Carotid Artery Stenosis
7 Intraoperative Monitoring
CEA Surgical Technique Essentials
1 Preoperative Management
2 Position and Intraoperative Monitoring
3 Intraoperative and Postoperative Blood Pressure Management
4 Surgical Exposure Technique
4.1 Variable Location of Carotid Bifurcation
4.2 Adequate Dissection and Gentle Retraction
4.3 Placement and Release of Clamping Forceps
4.3.1 The “External-Common-Internal” (ECI) Principle
4.3.2 Arterial Identification
4.3.3 Clamping Modality
4.3.4 Blocking Position
5 Arteriotomy and Plaque Dissection
6 Arteriotomy Closure
7 Closure
8 Postoperative Management
CEA Typical Cases
1 Incision, Exposure, and Surgical Indications
2 Surgical Timing
3 Carotid Stenosis with Ipsilateral Intracranial Aneurysm
4 Insufficient Compensation
5 Choice of the Side
6 Combined Heart Disease
7 High Carotid Plaque
8 Rotation of the Carotid Artery
Frequent Asked Questions of CEA
1 Anatomical Variations of CB Location and Morphology
1.1 High CB or High Plaque
1.1.1 Absolute High CB
1.1.2 Relatively High CB
1.2 Low CB
1.3 Carotid Tortuosity
1.4 Carotid Dissection
2 “Hai” Carotid Sheath (HCS)
2.1 Introduction of “Hai” Carotid Sheath (HCS)
2.2 “Hai” Carotid Sheath Dissection
3 Carotid Rotation
4 Characteristics of Carotid Plaque
4.1 Discrepancy between Operative Findings and Angiography of Carotid Plaque Length
4.2 Carotid Plaque Calcification
4.3 Carotid Occlusion
5 Management Strategy during Operative Exposure
5.1 Exposure of SCM, IJV, and Unexpected Bleeding
5.2 Manipulation of the Common Facial Vein (CFV), Transverse Cervical Nerve (TCN), and the Greater Auricular Nerve (GAN)
6 Carotid Opening and Repair
6.1 Location of Carotid Opening
6.2 Carotid Wall Rupture
6.2.1 ECA or its Branches
6.2.2 CCA
6.2.3 ICA
6.3 Bleeding from Vaso Vasorum of Carotid Arteries
6.4 Carotid Occlusion
6.5 Intraoperative Detriment of Tunica Media: Crack or Avulsion
6.6 Postoperative Cervical Hematoma
6.6.1 Arterial Origin
6.6.2 Venous Origin
7 Issues about the Clamping
7.1 Precaution of Ecclasis of Atheromatous Plaque
7.2 Inadequate Clamping and Arterial Leakage
8 Hyper-Perfusion Syndrome (HPS)
8.1 Mild
8.2 Moderate
8.3 Severe (Hemorrhage)
9 Carotid Restenosis
10 Cardiac Arrest
11 Postoperative Hypotension
12 External Carotid Endarterectomy
Summarized Process of CEA
1 Pre-op Management
2 Surgical Team Preview
3 Surgical Steps
3.1 Preparation Period
3.2 Intraoperative Procedure
3.3 Postoperative Prescription
3.4 Postoperative Check
3.5 Expected Complications
3.6 Follow-up
Appendix: Carotid Endarterectomy Specialized Instrument Set
Special Instruments of CEA