Eversion Carotid endarterectomy illustrated: Tips and tricks of the procedure

May 25, 2007
Surgical Rounds®, August 2006, Volume 0, Issue 0

N. Saratzis, Assistant Professor of Vascular Surgery; A. Saratzis, Resident; S. Miliaras, Senior Lecturer in Surgery; G. Ginis, Resident; N. Melas, Resident; A. Lioupis, Resident; D. Lycopoulos, Resident; J. Lazarides, Senior Lecturer in Vascular Surgery; D. Kiskinis, Professor, Head of Department, First Department of Surgery, Papageorgiou General Hospital, Aristotle University Medical School, Thessaloniki, Greece

Eversion carotid endarterectomy (ECEA) has been used for some time as a method for preventing stroke. Numerous groups have adopted this technique. In particular, The Vascular Group, PLLC, in Albany, New York, has written extensively on ECEA, pointing out its numerous advantages. One of the obvious advantages is speed. Because ECEA is technically a faster operation to perform, the question of shunting usually becomes secondary. This technique is also beneficial for patients who do not want to use a synthetic patch following the procedure. By performing an ECEA, the internal carotid artery serves as the patch. As Saratzis and colleagues indicate, another advantage of ECEA is that it addresses the long tortuous or kinked carotid artery, making it easy to foreshorten this vessel. Although ECEA is not commonly used in the United States, surgeons who perform carotid surgery should be familiar with this technique because it may be necessary at certain times.

Samuel R. Money, MD Head, Section of Vascular

Surgery

Ochsner Health System

New Orleans, LA

N. Saratzis, MD

Assistant Professor of

Vascular Surgery

A. Saratzis, MD

Resident

S. Miliaras, MD

Senior Lecturer in

Surgery

G. Ginis, MD

Resident

N. Melas, MD

Resident

A. Lioupis, MD

Resident

D. Lycopoulos, MD

Resident

J. Lazarides, MD

Senior Lecturer in

Vascular Surgery

D. Kiskinis, MD

Professor, Head of

Department

First Department

of Surgery

Papageorgiou General

Hospital

Aristotle University

Medical School

Thessaloniki, Greece

Carotid endarterectomy (CEA) is a well-established method for preventing stroke and is recognized as the gold standard for both symptomatic and asymptomatic patients with high-grade extracranial carotid artery stenosis.1 The two methods of CEA include conventional and eversion carotid endarterectomy (ECEA). Conventional CEA involves longitudinal arteriotomy of the internal carotid artery (ICA), removal of any plaque, and closure of the arteriotomy using a continuous simple suture, a patch made from synthetic material, or an autologous vein graft. Although conventional CEA is the most frequently employed technique, ECEA is a good alternative. ECEA involves complete transection of the ICA at its origin, removal of the atheroma while the adventitia of the ICA is everted, and reimplantation of the ICA on the common carotid artery (CCA). ECEA can prove useful in cases with carotid elongation and should be incorporated in the armamentarium of every vascular surgeon.

During the past several years, open carotid surgery has been sidelined in favor of less invasive techniques such as carotid angioplasty and stenting2; however, carotid stenting should be avoided in cases of severe carotid elongation because a nonflexible metal stent can cause severe kinking of an elongated and tortuous vessel. In such cases, ECEA should be the method of choice. We detail the steps of an ECEA and include a series of figures for further clarification.

ECEA: Steps of the procedure

The patient is placed supine on the operating table with the head hyperextended and turned to the opposite side. A 5- to 6-cm incision is made parallel to the anterior border of the sternocleidomastoid muscle. Electrocautery is used to incise the platysma muscle. The sternocleidomastoid muscle is retracted laterally, and after division and ligation of the facial vein, the carotid bifurcation is exposed.

The CCA, external carotid artery (ECA), and ICA are exposed and clamped. Systemic heparinization is necessary. A right-angled bulldog clamp should control the ICA well beyond the distal end of the atheromatous plaque (Figure 1).

The CCA is entered with a scalpel. Using angulated Pott's scissors, the arteriotomy is extended in a distal direction towards the fork of the carotid bifurcation (Figure 2). The incision should be made precisely parallel to the axis of the ICA. A common pair of scissors is then used for complete transection of this vessel (Figure 3). The transection permits complete mobilization of the artery. Additional traction downwards offers further length of exposure.

Endarterectomy is started at the stump of the ICA, and the plane is developed between the outer layers of the media and the adventitia (Figure 4). Fine atraumatic vascular forceps are used to circumferentially separate and detach the atheroma, while the outer layer of the vessel is everted (Figure 5). The eversion progresses distally, and the atheroma is detached like a cast (Figure 6). Gentle traction is used to completely remove the atheromatous core, leaving a thin, tapering end point (Figure 7). While the atheroma is removed, the luminal surface and the transition between the endarterectomized and the nonendarterectomized segments of the ICA are carefully assessed. The field is flooded with copious quantities of heparinized saline to remove intimal or medial debris. Flaps or loose residuals are removed gently by circumferential traction because cephalic traction can cause inadvertent intimal dissection of the ICA end point.

Next, endarterectomy of the ECA and CCA is attempted. The plaque is mobilized circumferentially using the closed jaws of a dissector (Figure 8). After proximal division of the plaque, the endarterectomy is carried out into the ECA orifice as distally as possible.

The arterial wall of the ICA is drawn proximally, and the surgeon initiates reimplantation of the artery to its normal position. The anastomosis is started at the bifurcation fork, using a simple, running, 6-0, synthetic monofilament suture. The posterior wall is reconstructed first, with tiny suture bites (Figure 9). Before completing the anterior wall of the anastomosis, each clamp is removed sequentially to allow back bleeding and to wash out any thrombogenic debris. At this stage of the procedure, the extracranial segment of the ICA may be dilated using appropriately sized dilators measuring up to 4.5 mm in diameter (Figure 10).

Angioscopy may be used to verify the anatomic result. Angioscopy provides excellent visualization of the whole endarterectomized luminal surface and the end point of the ICA (Figure 11). In case of incomplete endarterectomy or an unsatisfactory anatomic result, intraoperative stent deployment can be used to secure the distal end of the intima (Figure 12). These defects may be well documented using intraoperative completion arteriography. After the anastomosis is completed, blood flow is restored first to the ECA and then to the ICA. In some complex cases, when the inner surface of the ICA is unsmooth and friable after the ECEA or the plaque is extended distally, it may be necessary to replace the ICA using a graft. In such cases, interposition of synthetic or saphenous vein grafts may be used (Figure 13).

Discussion

The concept of ECEA was first reported by DeBakey and associates in 1959.3 The technique involved complete transection of the CCA at the bifurcation level, followed by ECEA of both the ICA and ECA. Since these divided arteries remained and were joined in a bi-furcation, adequate eversion of the ICA and visualization of the distal plaque end point were almost impossible. As a result, this method was not widely accepted. In 1989, Kasprzak and Raithel presented a modification of the technique, involving oblique transection of the ICA at the bifurcation, which allowed complete cephalad mobilization of this vessel and excellent visualization of the end point.4 Moreover, an elongated ICA could be resected at the desired length and reimplanted at the carotid bulb.

ECEA has several advantages over conventional CEA. The longitudinal arteriotomy of the ICA is avoided, and, subsequently, the suture line does not interfere with the small distal lumen of the vessel. The anastomosis is reconstructed at the carotid bulb and is rather large in diameter (2?3 cm). As demonstrated by Koskas and colleagues, this may be associated with avoidance of neointimal hyperplasia at the distal ICA and a lower restenosis rate than observed with conventional CEA.5

EVEREST (EVERsion carotid Endarterectomy versus Standard Trial) evaluated the feasibility and durability of ECEA. A total of 1,353 patients with surgical indications for carotid stenosis were randomly assigned to undergo ECEA (n = 678) or conventional CEA (n = 675). The groups had similar rates of perioperative major stroke and death (1.3 for each study group) and a similar incidence of early carotid occlusion (0.6% for ECEA versus 0.4% for conventional CEA). No significant differences were found between ECEA and conventional CEA with respect to incidence of perioperative transient ischemic accident, minor stroke, cranial nerve injuries, neck hematoma, myocardial infarction, or surgical defects. Overall 30-day events occurred in 13.3% of ECEA patients and 11.4% of conventional CEA patients. At a mean follow-up of 14.9 months, 16 (2.4%) restenoses occurred in the ECEA group and 28 (4.1%) occurred in the conventional CEA group.6,7

An advantage of ECEA is that it does not require use of a patch, even in patients with small arteries (particularly women). Closure is also technically easier and quicker. Radak and associates reported the mean clamping time for ECEA at 13.5 minutes versus 19.9 minutes for conventional CEA.7 ECEA is a highly effective method for correcting coiling, kinking, or tortuosities of the ICA in the presence of arteriosclerotic lesions. After completing the ECEA, an appropriately sized segment of the ICA is resected and the vessel is reimplanted.

Conclusion

Over the past decade, our center has performed ECEA on 278 patients. Restenosis occurred in 3 cases and 2 patients experienced an intraoperative stroke. These results and those of others, such as the EVEREST, indicate that ECEA is a feasible and safe technique for managing extracranial carotid arteriosclerosis. Major advantages of this technique are that it allows for optimum correction of an elongated ICA, has lower restenosis rates, and does not require patch material for arteriotomy closure.

References

1. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med. 1991;325(7): 445-453.

2. d'Audiffret A, Desgranges P, Kobeiter H, et al. Technical aspects and current results of carotid stenting. J Vasc Surg. 2001;33(5): 1001-1007.

3. DeBakey ME, Crawford ES, Morris GC Jr, et al. Surgical considerations of occlusive disease of the innominate, carotid, subclavian, and vertebral arteries. Ann Surg. 1961;154:698-725.

4. Kasprzak P, Raithel D. Eversion endarterectomy of the internal carotid artery [in German]. Vasa Suppl. 1992;37:83-84.

5. Koskas F, Kieffer E, Bahnini A, et al. Carotid eversion endarterectomy: short- and long-term results. Ann Vasc Surg. 1995;9(1): 9-15.

6. Cao P, Giordano G, De Rango P, et al. Eversion versus conventional carotid endarterectomy: late results of a prospective multicenter randomized trial. J Vasc Surg. 2000;31(1 pt 1):19-30.

7. Radak D, Radevic B, Sternic N, et al. Single center experience on eversion versus standard carotid endarterectomy: a prospective non-randomized study. Cardiovasc Surg. 2000;8(6):422-428.