Complications of carotid endarterectomy
- Ronald M Fairman, MD
Ronald M Fairman, MD
- Professor of Surgery and Radiology
- University of Pennsylvania School of Medicine
- Section Editors
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Science Center
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
- Scott E Kasner, MD
Scott E Kasner, MD
- Section Editor — Stroke
- Professor of Neurology
- University of Pennsylvania School of Medicine
The accepted indications for carotid endarterectomy (CEA) balance the long-term benefit of stroke reduction with the risk of perioperative complications, requiring overall morbidity and mortality rates associated with CEA to be low, otherwise the intervention cannot be justified. Complications following CEA can be related to underlying cardiovascular disease or other comorbid conditions, or to the technique of performing carotid endarterectomy.
Postoperative complications of CEA, including myocardial infarction, perioperative stroke, postoperative bleeding, and the potential consequences of cervical hematoma, nerve injury, infection, and carotid restenosis, which may require repeat carotid intervention, are reviewed here. The indications for carotid intervention are reviewed separately. (See "Management of asymptomatic carotid atherosclerotic disease" and "Management of symptomatic carotid atherosclerotic disease" and "Carotid endarterectomy".)
The accepted indications for carotid endarterectomy (CEA) balance the long-term benefit of stroke reduction with the risk of perioperative complications, requiring that overall morbidity and mortality rates associated with CEA should be low (<6 percent in symptomatic patients; <3 percent in asymptomatic patients) to justify the intervention [1,2]. The morbidity and mortality rates used by the American Heart Association (AHA) to formulate recommendations for CEA are more than 10 years old and based upon data that are even older. Two large randomized trials likely more accurately reflect the contemporary risk of stroke or death following CEA:
●The European trial (International Carotid Stenting Study [ICSS]) randomly assigned patients to receive carotid endarterectomy or carotid stenting for treatment of symptomatic carotid stenosis . The 120 day all-cause mortality for the 857 symptomatic patients in the endarterectomy group was 0.8 percent. The 120-day combined any stroke or procedural death rate was 4.2 percent.
●In North America, the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) reported combined results for symptomatic and asymptomatic patients . In 1240 patients assigned to endarterectomy (47.3 percent asymptomatic), the 30-day death rate was 0.3 percent, and the rate of any periprocedural (30-day) stroke or death or postprocedural ipsilateral stroke was 2.3 percent.
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- GENERAL CONSIDERATIONS
- PERIOPERATIVE STROKE
- Evaluation and treatment
- MYOCARDIAL INFARCTION
- HYPERPERFUSION SYNDROME
- CERVICAL HEMATOMA
- NERVE INJURY
- Frequency and distribution
- Specific nerves
- - Hypoglossal nerve
- - Facial nerve/mandibular nerve
- - Vagus /laryngeal nerves
- - Glossopharyngeal nerve
- - Sympathetic nerves
- Surgical site/patch infection
- CAROTID RESTENOSIS
- Risk factors
- Indications for reintervention
- CEA versus CAS for recurrent stenosis
- SUMMARY AND RECOMMENDATIONS