rate (major adverse cardiovascular event rate, MACE) of < 3% (evidence level 1b; recommendation grade A)
The following groups of patients are particularly able to benefit from the operation:
CEA should be carried out without delay in these cases (Eckstein et al. 2004).
Despite the lack of level 1a evidence, differential treatment consideration for carotid artery stenting (CAS) appears to be justified, above all in the presence of a “high carotid bifurcation” (bifurcation of the carotid artery higher than C2); for repeat operations in the neck; when there is paralysis of the contralateral recurrent laryngeal nerve; and after cervical radiotherapy, as it avoids local complications (e.g., nerve injuries).
Contraindications
Patient preparation
Preparations for the operation
The operation can be carried out either with regional anesthesia or general anesthesia, although a recent prospective randomized multicenter study (the GALA study) showed some advantages for regional anesthesia (Lewis et al. 2009).
Surgical access
The incision is made at the anterior margin of the sternocleidomastoid; preoperative assessment of the level of the carotid bifurcation can provide good guidance. The level of the palpable cricoid can also be used for guidance. The skin incision is usually approximately 7 cm long, and it is carried cranially toward the inferior margin of the earlobe. As far as possible, the incision should be made as little cranially or ventrally from the earlobe as possible, as injury to the oral branch of the facial nerve could occur, either directly or due to a subsequent retractor movement, leading to pareses in the ipsilateral corner of the mouth postoperatively.
After division of the skin, subcutaneous tissue, and platysma, the common carotid artery, which is usually easily palpated, is dissected and looped with a vascular sling. Following exposure of the common carotid artery, the internal carotid artery is exposed above the carotid bifurcation. Unnecessary manipulations of the vessel are avoided to avoid triggering embolizations (“no-touch” technique). During further dissection of the bulb in the direction of the internal carotid, the ansa cervicalis of the hypoglossal nerve is spared as much as possible. However, it may also be transected if necessary, usually without sequelae. Following it cranially leads to the hypoglossal nerve as it crosses the internal carotid artery. Particularly when there is a high carotid bifurcation, the hypoglossal nerve has to be mobilized, and the sternocleidomastoid branches of the occipital artery and vein attached to it have to be ligated. Circular exposure of the carotid bifurcation is only carried out after clamping of the internal carotid artery, in order to prevent embolization (Fig. 1.1-19a, b).
Surgical procedure
There are basically two procedures that can be used for plaque removal and reconstruction of the internal carotid artery or carotid bifurcation: