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%)