Surgical intervention in the area of carotid stenosis Classical carotid endarterectomy case report Kallob.Mohammed1,Asad.Asad2, Yasser Elkhaldi3, Sheikh.Abdelrahman4

1Department of vascular surgery, EGH, Gaza, Palestine, 2General surgery department, EGH, Gaza, Palestine,3Department of anesthesiology, EGH, Gaza, Palestine, 4 Faculty of medicine, Islamic University of Gaza, Gaza, Palestine.

Stroke is defined as a cerebrovascular accident with the development of

persistent symptoms of central nervous system, the nature of which

depends on the location and extent of the damaged area of the brain.

According to the World Federation of Neurological Societies, the world

each year is recording at least 15 million strokes. In the U.S., stroke is

the third leading cause of death each year 500,000 strokes. From these

strokes and its complications in the U.S. die 150,000 people a year.

80-85% of Ischemic strokes is caused by atherosclerosis of the arteries

of the head and neck, affecting small cerebral arteries due to

hypertension, diabetes or cardiac emboli.

Mortality after an ischemic stroke is 20% within the first month and

about 25% for the first year. 6 months after stroke disability occurs in

40% of survivors.

Medical treatment of transient attacks and small strokes practically

protects patients, and 52-55% within 3 years comes a large cerebral

infarction, however the incidence of recurrent strokes or transient

ischemic attacks within 5 years in patients operated for atherosclerotic

vascular lesions of the neck is 1-3%.

In 1953 the first case of trombendarterectomy has been successfully

applied in the defeat of the carotid artery. M. DeBakey, Houston, Texas.

In 1984, Kieny R. c et al., performed carotid endarterectomy by eversion

technique

Case presentation

70 years old male patient was admitted to the department of vascular surgery in EGH complaining of recurrent transient ischemic attacks, On his medical history there was hypertension, dyslipidemia, DM and Severe coronary artery disease (CAD) Post cabbage in 2010. The patient was on clexan Forta 200 u daily. The patient underwent duplex US of carotid vessels that showed

bifuricational and right internal carotid artery stenosis of more

than 80% and the results was confirmed by CT angiograph.

The plaque was found to be calcified with ulceration and micro

thrombi (Type V), the surgery was decided to relieve patients

symptoms and to prevent further attacks and brain Ischemia.

Intra-operatively, Classical carotid endarterectomy was done

without temporary shunt due to high tolerance of brain ischemia

(pre-operative study)

Total blood loss was 200 cc, total operation time was 1hr 30 min.

The patient was extubated in the OR, with normal superficial

reflexes and transferred to the department in a good general

condition.

Follow-up visits at 1 and 24 months after surgery were unremarkable.

Duplex US was done in the last visit and showed no stenosis.

Figure.1 Exploration of internal carotid artery Figure.2 plaque after removal

Discussion

160,000 operation of Carotid endarterectomies are performed

each year in U.S., in contrast, Stenting and balloon angioplasty

(according to different countries) accounts for about 15-25% of

total number of cases with carotid stenosis.

Long-term results of surgical treatment are far superior in their

effectiveness to the carotid angioplasty method zone.

Color Duplex ultrasound scanning is considered to be the main

method for detection of significant stenosis in the carotid region

(Any stenosis > 50%, Sensitivity 98%, specificity 88%), (Any

stenosis > 70%, Sensitivity 90%, specificity- 94%).

Surgical intervention is indicated in Stenosis> 70%, Embologenic

stenosis 50-69%, Acute thrombosis of the ICA and if the plaque is

type V.

Medical intervention is indicated for small and medium stenosis,

that are not causing recurrent ischemic attacks and upon the

occurrence of ischemic stroke

Conclusion

Therapeutic treatment should be carried out in conjunction with

surgery to achieve the best results as the Long-term results of

surgical treatment substantially improves the quality of life and

health of patients over a long period.

Screening by duplex US is recommended for all patients with high

risk for developing carotid stenosis especially those over 60 years,

smokers, hypertensive and diabetics patients.

References Carotid Artery Disease, Stroke, Transient Ischemic Attacks (TIAs), Vascular Web, November

2010.

Improvement in accuracy of diagnosis of carotid artery stenosis with duplex ultrasound scanning

with combined use of linear array 7.5 MHz and convex array 3.5 MHz probes: validation versus

489 arteriographic procedures.

Leonardo G1, Crescenzi B, Cotrufo R, Tecame S, De Santo LS, Della Corte A, Fratta M, Cotrufo M.

J Vasc Surg. 2003 Jun;37(6):1240-7.

Validating common carotid stenosis by duplex ultrasound with carotid angiogram or computed

tomography scan.

Matos JM1, Barshes NR2, Mccoy S3, Pisimisis G2, Felkai D3, Kougias P2, Lin PH1, Bechara CF4.

J Vasc Surg. 2014 Feb;59(2):435-9. doi: 10.1016/j.jvs.2013.08.030. Epub 2013 Sep 29.

Dawson DL, Zierler E, Strandness DE Jr, Clowes AW, Kohler TR. The role of duplex scanning and

arteriography before carotid endarterectomy: a prospective study. J Vasc Surg. 1993;18:673-

683.

Faught WE, Mattos MA, van Bemmelen PS, Hodgson KJ, Barkmeier LD, Ramsey DE, Sumner DS.

Color-flow duplex scanning of carotid arteries: new velocity criteria based on receiver operator

characteristic analysis for threshold stenoses used in the symptomatic and asymptomatic

carotid trials. J Vasc Surg. 1994;19:818-828.