[Surgery of high-grade asymptomatic stenosis of the internal carotid artery]

Surgery of carotid artery stenosis is an evidence-based procedure. In Germany approximately 25 percent of the strokes are caused by arteriosclerotic processes in the extracranial internal carotid artery and are consequently potentially avoidable by an appropriate treatment. The symptoms, the stenosis degree as well as the perioperative risk represent the basis for the indication. The perioperative complication rate should be under 3 percent for those cases with asymptomatic stenoses and under 6 percent for those with symptomatic stenoses.

The most frequently applied operation procedures comprise carotid thrombo-endarterectomy (TEA) including patch graft and the eversion endarterectomy. In the following video we present both methods in a 76-year-old female patient with an asymptomatic 95 percent stenosis as well as in an 84-year-old female patient with an asymptomatic 85 percent stenosis operated under regional anaesthesia.

Regional anaesthesia is performed through installation of a high cervical block under reclination of the head to the contralateral side. Then incision of the skin and the platysma along the front of the sternocleidomastoid muscle. Preparation of the carotid bifurcation with minimal manipulation as well as protection of the surrounding neural structures. Afterwards clamping of the vessels under permanent neurological monitoring and controlled hypertonia. Open thrombo-endarterectomy after longitudinal arterial incision with plaque removal en bloc and closure by using a bovine patch graft in four-point seam technique. This method should be preferred in cases with long-segment stenosis as well as in cases with a small lumen internal carotid artery. In the framework of eversion endarterectomy, we perform a tangential resection of the ACI on the bifurcation. The plaque cylinder is mobilised afterwards and is removed through eversion of the whole vessel. Then the reinsertion of the ACI in the bifurcation can be performed with an additional shortening of the artery in cases of kinking. In this way short- segment stenosis lend themselves to fast and safe treatment. In all cases digital subtraction angiography is recommended by the authors for intraoperative quality monitoring.

In the hands of experienced vascular surgeons, the open carotid TEA including patch graft and the eversion endarterectomy under regional anaesthesia represent highly effective procedures for symptomatic/asymptomatic carotid stenosis. The S3-guidelines for the therapy of carotid artery stenosis will be published this year and should be consulted for the interdisciplinary therapy decision.