Authored by Dr. Jeffrey Rubin, MD. Presented at the First Annual Omar P. Haqqani MD Vascular Symposium, November 10, 2016, Midland Country Club, Midland, MI.

1. Complicated Open Carotid
Interventions
Jeffrey R. Rubin, MD, FACS
Professor and Chief Vascular and Endovascular
Surgery
Wayne State University and Detroit Medical Center

2. Carotid Artery Disease
• Atherosclerosis
• Fibromuscular Dysplasic
• Coils and kinks
• Aneurysm
• Arteritis (inflammatory or radiation induced)

7. Carotid Plaque
• Smooth
• Irregular
• Ulcerated (small, large, multiple)

11. Risk of stroke, myocardial infarction or
death must be <3% to benefit patient

12. • Carotid stenting
• Carotid endarterectomy
– Standard
– Eversion
• With OR without patch

15. Primary Restenosis
Carotid artery restenosis following
endarterectomy and stenting ranges
from 1-20% nationally

16. Primary Restenosis
• <2 Months => Technical Problems
• <24 Months => Intimal Hyperplasia
• >24 Months => Recurrence or Progression of
Disease

17. Primary Restenosis
• Hyperplastic => 65%
• Complex/Heterogeneous => 18%
• Complex w/Thrombus/ I/P Hemorrage => 17%

18. Primary Restenosis
• Asymptomatic => 74%

19. Redo CEA
Clinical Dilemma : Open vs. Stenting

20. Redo CEA
Open Redo Intervention
1.Neck hostility
2.Location of lesion
3.Overall patient health
4.Skill level of surgeon

21. Evaluation
• CAROLTID DUPLEX SCANNING
• High sensitivity, specificity, accuracy
• Plaque Morphology
• Areas of Involvement
• Bifurcation

22. Evaluation
CTA with IV contrast

23. Evaluation
Angiography

25. Preoperative Evaluation
• Laryngoscopy
• Head CT Scan ?
• Control of hypertension

26. Redo CEA
Surgical Options
•Redo endarterectomy & patch angioplasty
•Patch angioplasty alone
•Resection and vein / Artery interposition
grafting

31. Complications
• Hematoma
• Myocardial ischemia
• TIA / CVA
• Restenosis

32. Complications
Cranial Nerve Injuries
•Hypoglossal
•Vagus
•Marginal mandibular
•Superior Laryngeal
•Glossopharyngeal
•Spinal Accessory

33. Cranial Nerve Injuries
After RCEA = 13%
•80% Temporary (Recovery <30 days)
•16% Prolonged (Recovery >30 days)
•4% Permanent

34. Open Redo Endarterectomy
• Stroke => 0%
• Myocardial infarction => 0.5% (1 of 192)
• Death => 0%

35. Redo CEA
Incidence of cerebrovascular events after
Carotid artery stenting for RCAD = 2.2%
National Cardiovascular Data Registry

36. Redo CEA
Incidence of cerebrovascular events after redo
carotid artery open intervention = 0%

37. Redo CEA
• <1% First time CEA developed significant
recurrence
• 1.5% RCEA’s developed significant recurrence
(others => 4.6^ - 11%)