Endarterectomy
Carotid endarterectomy is a surgical procedure that removes atheromatous plaque from the inner lining of the carotid arteries. This improves intracranial perfusion by increasing blood flow through the carotid arteries.
Carotid endarterectomy may help patients with reversible ischemic neurologic deficit or a completed stroke. Patients who experience transient ischemic attacks (TIAs), syncope, and dizziness, and those who have high-grade asymptomatic or ulcerative lesions, may also benefit from this procedure.
Other beneficiaries of carotid endarterectomy include patients with concurrent coronary artery disease. The procedure may relieve both conditions in one operation (in patients who are neurologically stable and otherwise good surgical risks). Because carotid lesions commonly lead to stroke in both symptomatic and asymptomatic patients, some surgeons consider this operation a prophylactic treatment for stroke. However, many intraoperative and postoperative risks are associated with the procedure, making it unsuitable for some patients. (See Risk levels of carotid endarterectomy, page 276.)
Procedure
Cervical block anesthesia and sedatives, which allow the patient to be closely monitored, are usually used during a carotid endarterectomy. Alternatively, light general anesthesia may be used so that brain waves can be assessed.
An incision is made along the anterior border of the sternocleidomastoid or transversely in a skin crease in the neck. Next, the common carotid artery, external carotid artery, and internal carotid artery are exposed, and the carotid artery is clamped to evaluate perfusion. If cerebral perfusion is inadequate, a shunt is inserted to permit blood flow past the obstruction in the carotid artery and to ensure adequate cerebral circulation during surgery.
Once the carotid artery is stabilized, a heparin infusion is started to prevent thrombosis. The affected arteries are then incised, and the plaque is dissected. Next, the artery is patched with an autogenous saphenous vein or prosthetic material and closed. If a shunt is in place, it’s removed before closure is completed.
Complications
The most common complication of carotid endarterectomy is blood pressure lability. Transient hypertension also occurs frequently from manipulation of the carotid body. Perioperative stroke, the most serious complication, may result from the embolization of debris during dissection.
Temporary or permanent loss of carotid body function may occur. Blood pressure and ventilation normally increase in response to hypoxia; however, with the loss of carotid body function, blood pressure and ventilation decrease in response to hypoxia. Other complications include recurrent thrombosis, postoperative respiratory distress caused by tracheal compression from a hematoma, and wound infection at the surgical site.
An uncommon complication is a sudden increase in cerebral blood flow, which can lead to ipsilateral vascular headaches, seizures, and intracerebral hemorrhage. Rarely, vocal cord paralysis may arise from manipulation of the vagus nerve.
Key nursing diagnoses and patient outcomes
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