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Page: Procedure
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The internal, common and external carotid arteries are clamped, the lumen of the internal carotid artery is opened, and the atheromatous plaque substance removed. The artery is closed, hemostasis achieved, and the overlying layers closed. Many surgeons lay a temporary shunt to ensure blood supply to the brain during the procedure. The procedure may be performed under general or local anaesthesia. The latter allows for direct monitoring of neurological status by intra-operative verbal contact and testing of grip strength. With general anaesthesia indirect methods of assessing cerebral perfusion must be used, such as electroencephalography (EEG), transcranial doppler analysis and carotid artery stump pressure monitoring. At present there is no good evidence to show any major difference in outcome between local and general anaesthesia.
Non-invasive procedures have been developed, by threading catheters through the femoral artery and up through the aorta, and then inflating a balloon to to dilate the carotid artery, with or without a wire-mesh shunt. In SAPPHIRE, this procedure, known as carotid stenting, was shown to be non-inferior to carotid endarterectomy in total adverse events, and actaully showed lower event rates for major stroke, cranial nerve palsy, and myocardial infarction, in patients at high risk for surgery. Ongoing studies are being conducted in the broader non-high-risk population.
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