Joel ArudchelvamConsultant Vascular and

Transplant Surgeon

In Carotid artery disease Vertebral artery disease Brachio-cephalic artery disease

Brain is supplied by 2 carotid and 2 vertebral arteries.

carotid artery divides in carotid triangle into Internal carotid

artery (ICA) External carotid

artery (ECA)

at the upper border of thyroid cartilage

No branches to ICA in the neck

Formed by branches of bilateral carotid and basilar artery

Basilar artery - union of vertebral arteries

Allows collateral flow

TIA - focal neurological deficit lasting <24 hours

Stroke - symptoms continue for >24 hours Nondisabling stroke - a residual deficit

associated with a score ≤2 according to the Modified Rankin Scale.

0 - No symptoms 1 - able to carry out all usual activities 2 - unable to carry out all previous activities, but able to look after

without assistance 3 - Moderate disability; requiring some help, able to walk without

assistance 4 - Moderately severe disability; unable to walk without assistance

and unable to attend to own bodily needs without assistance 5 - Severe disability; bedridden, incontinent and requiring constant

nursing care 6 - Dead

The degree of stenosis - velocity criteria

higher the velocity the - greater the stenosis

Normal: PSV < 125 cm/s , no plaque is visible.

< 50% stenosis: PSV < 125 cm/s and plaque is visible.

50-69% stenosis: PSV is 125-230 cm/s and plaque is visible.

>70% stenosis to near occlusion: ICA PSV >230 cm/s and visible plaque

Total occlusion: No flow seen

Interobserver agreement = higher

• 70 - 99% - CE (Level A).

• 50-69% - CE may be considered (Level B) (at least a five year life expectancy )

• <50% stenosis - CE not be considered (Level A). Medical management (Level

A).

• Total occlusion – no need of revascularisation

• Non disabling ischemic stroke or transient ischemic attacks (within 6 months)

• Fit for surgery

NICE guidelines – within 2 weeks

No place of emergency surgery in patients with

unstable presentation

Due to haemorrhagic transformation and unprepared

patient high (allow stabilisation of infarction)

Stop Smoking Blood pressure control (less than 140/90

mmHg) Antiplatelet agents Cholesterol lowering drugs / diet ( LDL

less than 100 mg/dL) Lifestyle advice

Modes Local infiltration Cervical plexus block GA

Aim Maintain cerebral perfusion Reduce cardiac workload Allow smooth recovery to assess neurological

status

Invasive arterial blood pressure monitoring/stump pressure (70mmHg)

maintain blood pressure Maintain CO2 tension –avoid hyper / hypo Agents –

Induction Thiopentone - protect against focal ischaemia Propofol – rapid awakening etomidate CV stability

Maintenance with volatile agent – Isoflurane

Neurological monitoring EEG, transcranial Doppler

•Nerves to preserve –•Hypoglossal•Vagus•Marginal mandibular

Perioperative stroke – 7.4% (2/27)* Haematoma Hyper perfusion syndrome Nerve injury -7.4% (2/27)*

Hypoglossal Vagus

Infection

JD Arudchelvam , et.al. carotid endarterectomy: experience in a single vascular unit.presented as an abstract at annual academic sessions of the college of surgeons, Sri Lanka , Aug 2012.

Keep propped up, O2 Control blood pressure (surgical

disturbance of baro receptors) -Use short acting anti-hypertensive agents such as labetolol Especially within 48 hours hyperperfusion syndrome, haematoma

Check document neurological status

CT scan

In high grade stenosis

Results in cerebral oedema,

haemorrhage

Unilateral headache, seizures

Carotid stenting

Difficult surgical access radiation, previous neck surgeries

Medically not fit for surgery

Stroke / TIA

Early imaging

Optimization / best medical treatment

Vascular referral

Thank you