Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3810_Библиотеки_им_академика_М_И_Перельмана

Since its introduction nearly 75years ago, there have been few modications to the technical approach of standard carotid endarterectomy (CEA). Indications for carotid stenosis to reduce the risk of stroke and other neurologic complica­tions in selected patients have been published in large randomized studies [1, 2]. In 2008, the Society for Vascular Surgery (SVS) summarized evidence-based clinical practice recommenda­tions for the management of carotid stenosis [3]. Carotid duplex ultrasonography is currently the preferred imaging modality for the diagnosis of carotid artery stenosis due to its safety, availabil­ity, and reliable results. However, duplex ultra­sound is highly operator-dependent. Thus, computed tomography angiography (CTA), mag­netic resonance angiography (MRA), and con­ventional angiography can be used to detect plaque morphology, identify technically difcult lesions, and plan for standard CEA, eversion CEA, or carotid stenting.

CEA is associated with appreciable rates of persistent or recurrent stenosis [4]. Management of the end point may be tedious, and closure of the arteriotomy may be problematic. Eversion endarterectomy with reimplantation is preferred if the internal carotid artery is elongated, is less than 4 mm wide, and occurs in women [5]. As medical management of atherosclerotic risk fac­tors and perioperative care improves, the out­come differences attributed to these small but signicant technical details embody the “holy grail” of carotid atherosclerosis surgery. The con­temporary method of ECEA is an alternative technique to facilitate the removal of plaque iso­lated to the carotid bulb and proximal internal carotid artery (ICA). Advantages of eversion ver­sus standard endarterectomy include the ability to shorten a redundant ICA, better visualized end point and easier detection of intimal aps, faster closure by simple anastomosis of the ICA to the carotid bulb, an all-autogenous reconstruction, and decreased restenosis rates in women.

Anesthetic choice, cerebral monitoring, and neuroprotection are identical for both methods of CEA.During the case, neurologic monitor­ing is routine. The use of shunting and/or moni­toring of cerebral functions is determined by the attending surgeon and anesthesiologist.

Electroencephalographic (EEG) monitoring is used for patients under general anesthesia, while continuous neurological assessment is used for patients undergoing CEA under cervi­cal block anesthesia. Most patients undergoing CEA do not require intraoperative shunt place­ment. If shunting is needed during ECEA, insertion of the shunt is performed after evert­ing and removing the bulk of the ICA plaque. We prefer to use the short Sundt (internal shunt) with non-reinforced segment, 3 mm × 4 mm (Integra NeuroSciences™, Plainsboro, NJ). Shunt insertion is performed distally into the ICA and held in place with a shunt clamp. An extension of the common carotid arteriotomy may be needed to expose the open lumen prior to shunt insertion into the common carotid artery (CCA). Eversion endarterectomy is the preferred procedure for ICA carotid kinks or loops. After transection, redundant ICA may be resected and anastomosis completed to a more distal portion of the ICA.Initial neck dissection and isolation of the carotid artery are similar to the conventional CEA technique. Dissection and mobilization of the carotid bulb and proxi­mal ICA are more extensive with ECEA than standard CEA.The need for more extensive dis­section for ECEA has not caused an increase in vagus nerve injury. Some surgeons mark the level of the carotid bulb with ultrasound prior to skin incision to minimize the length of the incision.