c















 
A carotid endarterectomy is a surgical procedure in which a doctor removes fatty deposits
blocking one of the two carotid arteries, the main supply of blood for the brain. Carotid artery
problems become more common as people age. The disease process that causes the buildup of fat
and other material inside the artery walls is called atherosclerosis, popularly known as
"hardening of the arteries." The fatty deposit is called plaque; the narrowing of the artery is
called stenosis. The degree of stenosis is usually expressed as a percentage of the normal
diameter of the opening.










Carotid endarterectomy is performed to prevent stroke. Two large clinical trials supported by the
National Institute of Neurological Disorders and Stroke (NINDS) have identified specific
individuals for whom the surgery is beneficial when performed by surgeons and in institutions
that can match the standards set in those studies. The surgery has been found highly beneficial
for persons who have already had a stroke or experienced the symptoms of a stroke and have a
severe stenosis of 70 to 99 percent. In this group, surgery reduces the estimated 2-year risk of
stroke or death by more than 80 percent, from greater than 1 in 4 to less than 1 in 10.

For patients who have already had transient or mild stroke symptoms due to moderate carotid
stenosis (50 to 69 percent), surgery reduces the 5-year risk of stroke or death by 6.5 percent. The
failure rate for ipsilateral stroke or death for the medical group is 22.2 percent, and for the
surgery group is 15.7 percent from greater than 1 in 4 to less than 1 in 7. Individuals who have
already had stroke symptoms, and who have carotid stenosis greater than 50 percent, may wish
to consider surgery to prevent future stroke. With the completion of the NASCET trial, patients
with moderate (50 to 69 percent) stenosis will be better able to make more informed decisions.

In another trial, the procedure has also been found highly beneficial for persons who are
symptom-free but have a carotid stenosis of 60 to 99 percent. In this group, the surgery reduces
the estimated 5-year risk of stroke by more than one-half, from about 1 in 10 to less than 1 in 20






  !






Important risk factors in addition to the degree of stenosis include, gender, diabetes, the type of
stroke symptoms, and blockage of the carotid artery on the opposite side. Without other
complicating illnesses, age alone is not a worrisome risk factor. Risk factors can affect patients
in two ways. They can, particularly in combination, greatly increase a person's risk of having a
stroke. In addition, these risk factors can increase the likelihood of surgical complications.
"#



 "




$
 

The mainstay of stroke prevention is risk factor management: smoking cessation, treatment of
high blood pressure, and control of blood sugar levels among persons with diabetes.
Additionally, physicians may prescribe aspirin, warfarin, or ticlopidine for some individuals.

The mainstay of stroke prevention is risk factor management: smoking cessation, treatment of
high blood pressure, and control of blood sugar levels among persons with diabetes.
Additionally, physicians may prescribe aspirin, warfarin, or ticlopidine for some individuals.

á
 

 

Extracranial to intracranial (EC-IC) bypass is a surgical procedure to increase cerebral blood

flow. This procedure entails connecting a branch of the external carotid artery (usually the
superficial temporal artery) to a branch of the internal carotid artery (usually the middle cerebral
artery), either directly or via a vein graft. This procedure is similar to cardiac bypass surgery
where blocked heart arteries are bypassed.

EC-IC bypass has been available as a potential treatment for ischemic stroke for the past 30
years. There has been much controversy concerning this procedure due to a large study
conducted in the 1980s. As a result, this procedure is only used in a very select group of patients.




The indications for EC-IC bypass are severe stenosis or occlusion

of 
  arteries with focal neurological symptoms, such
as weakness or speech difficulties. This procedure is also used
when an artery must be surgically occluded for the treatment of
unclippable giant aneurysms. In children, this procedure is used
to treat Moya-moya disease (a progressive narrowing of the
proximal 
  blood vessels).

2 

A craniotomy is performed to expose the intracranial vessels and

the location of obstruction or giant aneurysm. The donor artery is exposed (scalp or neck). If
needed, a vein is harvested from the leg. The anastamosis is performed under the operating
microscope. Once complete, the bypass is examined in the operating room with an angiogram.
Ô
 
    
Ô
? 
? ?
 ? ?
  ??

 ?

?

???
 ??
?


?

?
? 
?? ??? ???
?


? 
??

?

?
? ?

 ?
?? ? ??

?
?
 ?
??

? ?
??
 ?
 ? ?
?


? ???  
?
?


?

Îatients are awake during the procedure, and are usually discharged from the hospital the
following day. Most patients are able to resume normal activities when they get home.

$ 


j? ocal instead of general anesthesia

j? Fewer surgical complications such as nerve injury, hematoma (bruising) and wound
infection
j? Shorter operation
j? ess discomfort
j? Smaller incision
j? Shorter recovery time
j? Ability to treat narrowed arteries that are hard to reach or difficult to treat with surgery

Because carotid angioplasty is a relatively new procedure, its durability and long-term ability to
deter stroke are still under study. Your physician will talk with you about the risks of this
procedure.