Management

Carotid endarterectomy is done through a neck incision along the anterior border of the sternocleidomastoid muscle. The carotid is isolated with vessel loops. The patient is heparinized to weight and the internal carotid is then clamped after 3 minutes. Some surgeons routinely shunt at this point regardless of backbleed pressures (> 50 mm Hg). Current recommendations are to shunt if expected clamp time is > 20 minutes and/or poor retrograde pressure. Injection of the carotid body with lidocaine is an option for control of pressure shifts due to manipulation.

Current studies recommend closure with some type of patch angioplasty to minimize restenosis. The optimal choice of material has been left to surgeon choice. Allen et al report their experience with ePTFE vs. saphenous vein patch and concluded that postoperative complications were the same but vein harvest site complications are eliminated with the use of ePTFE.2

Post procedure duplex scanning to assess for thrombosis, intimal flap or stenosis are more widely done. Approximately 5-8% of cases that undergo intraoperative duplex scanning are found to have stenosis that warrant revision.3,4

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