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Optimising care for carotid stenosis from screening to surgery
Optimising care for carotid stenosis from screening to surgery. Joel Arudchelvam
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Optimising care for carotid stenosis from screening to surgery
- 1. O OPTIMISING CARE FOR PTIMISINGCARE FOR CAROTID STENOSIS CAROTID STENOSIS FROM SCREENING TO SURGERY FROM SCREENING TO SURGERY Joel Arudchelvam Joel Arudchelvam MBBS(COL), MD(SUR), MRCS(ENG), FCSSL MBBS(COL), MD(SUR), MRCS(ENG), FCSSL Consultant Vascular and Transplant Surgeon, Consultant Vascular and Transplant Surgeon, Senior Lecturer in Surgery, Surgery Department Senior Lecturer in Surgery, Surgery Department Faculty of Medicine, University of Colombo, Sri Lanka. Faculty of Medicine, University of Colombo, Sri Lanka. International Stroke Conference Sri Lanka 2025
- 2. INTRODUCTION INTRODUCTION • Large vesselcerebrovascular disease – 15% • Extracranial internal carotid artery (ICA) stenosis / occlusion – 11.5% • Vertebral artery stenosis / occlusion – 1.4% • CEA done for the stenosis caused by CEA done for the stenosis caused by atherosclerotic plagues at the CA atherosclerotic plagues at the CA bifurcation bifurcation Lovett JK, Coull AJ, Rothwell PM. Early risk of recurrence by subtype of ischemic stroke in populationbased studies. Neurology. 2004;62:569– 573. doi: 10.1212/01.wnl.0000110311.09970.83.
- 3. INTRODUCTION INTRODUCTION • Large vesselcerebrovascular disease – 15% • Extracranial internal carotid artery (ICA) stenosis / occlusion – 11.5% • Vertebral artery stenosis / occlusion – 1.4% • CEA done for the stenosis caused by CEA done for the stenosis caused by atherosclerotic plagues at the CA atherosclerotic plagues at the CA bifurcation bifurcation Lovett JK, Coull AJ, Rothwell PM. Early risk of recurrence by subtype of ischemic stroke in populationbased studies. Neurology. 2004;62:569– 573. doi: 10.1212/01.wnl.0000110311.09970.83.
- 4. ANATOMY ● Right commoncarotid - brachiocephalic trunk ● Left common carotid artery – Aortic arch ● Bifurcate into the external and internal carotid arteries – 4th cervical vertebra
- 5. ANATOMY ANATOMY Nerves ●Hypoglossal nerve ●Vagus nerve ●Glossopharyngealnerve ●Great auricular nerve ●Marginal mandibular
- 6. ANATOMY ANATOMY Nerves ●Hypoglossal nerve ●Vagus nerve ●Glossopharyngealnerve ●Great auricular nerve ●Marginal mandibular
- 7. ANATOMY ANATOMY Nerves ●Hypoglossal nerve ●Vagus nerve ●Glossopharyngealnerve ●Great auricular nerve ●Marginal mandibular
- 8. ANATOMY ANATOMY Nerves ●Hypoglossal nerve ●Vagus nerve ●Glossopharyngealnerve ●Great auricular nerve ●Marginal mandibular
- 9. ANATOMY ANATOMY Nerves ●Hypoglossal nerve ●Vagus nerve ●Glossopharyngealnerve ●Great auricular nerve ●Marginal mandibular
- 10. ANATOMY ANATOMY Nerves ●Hypoglossal nerve ●Vagus nerve ●Glossopharyngealnerve ●Great auricular nerve ●Marginal mandibular
- 11. INVESTIGATIONS INVESTIGATIONS ● Carotid duplexscan (USS with Doppler) Carotid duplex scan (USS with Doppler) ● Computerised tomographic angiogram (CTA) Computerised tomographic angiogram (CTA)
- 12. CAROTID DUPLEX SCAN CAROTIDDUPLEX SCAN
- 13. CAROTID DUPLEX SCAN CAROTIDDUPLEX SCAN ● Normal Flow Normal Flow
- 14. CAROTID DUPLEX SCAN CAROTIDDUPLEX SCAN ● Turbulent flow Turbulent flow
- 15. CAROTID DUPLEX SCAN CAROTIDDUPLEX SCAN Degree of stenosis (%) ICA PSV (cm/s) Normal <125 Moderate >50% stenosis >125 60% stenosis >170 Severe >70% stenosis >230 Total occlusion Undetectable
- 16. COMPUTED TOMOGRAPHIC ANGIOGRAM(CTA) COMPUTED TOMOGRAPHIC ANGIOGRAM (CTA) ● Poor image quality ● A tandem intracranial stenosis / occlusion is suspected ● High carotid bifurcation ● Tortuosity ● Obesity ● Severe aortic valve insufficiency ● Reduced cardiac output Affect the recorded blood flow velocities Cutler, J.J.; Campo, N.; Koch, S. B-Flow and B-Mode Ultrasound Imaging in Carotid Fibromuscular Dysplasia. J. Neuroimaging 2018, 28, 269–272.
- 17. CT ANGIOGRAM (CTA) CTANGIOGRAM (CTA) ● NASCET and ECST NASCET and ECST ● Based on CTA ● NASCET = A – B / A ● ECST = C – B / C ● 50% NASCET = 75% ECST 50% NASCET = 75% ECST ● 70% NASCET = 85% ECST 70% NASCET = 85% ECST North American Symptomatic Carotid Endarterectomy Trial (NASCET), European Carotid Surgery Trial (ECST)
- 18. European Society forVascular Surgery (ESVS)
- 19. INDICATIONS INDICATIONS ● Symptomatic Symptomatic ● Morethan 60% stenosis More than 60% stenosis ● Patients undergoing CABG – bilateral total more Patients undergoing CABG – bilateral total more than 140% than 140%
- 20. CONTRAINDICATIONS CONTRAINDICATIONS ● Surgically unfitpatient Surgically unfit patient ● Previous extensive neck surgeries Previous extensive neck surgeries ● Previous neck irradiation Previous neck irradiation
- 21. CAROTID ENDARTERECTOMY CAROTID ENDARTERECTOMY Localor general anaesthesia ●GA – 93.6% GA – 93.6% ●LA – 6.4% LA – 6.4% Position Position ●Supine , the neck is extended and turned away from the side of operation.
- 22. CAROTID ENDARTERECTOMY CAROTID ENDARTERECTOMY Incision Incision ●Longitudinalincision along the anterior margin of the sternocleidomastoid muscle (SCM)
- 23. CAROTID ENDARTERECTOMY CAROTID ENDARTERECTOMY ●Dissection and Dissection and control of the control of the arteries arteries ● Early control of the distal ICA ● Heparin IV – before clamping
- 24. STUMP PRESSURE ● Beforeclamping – MAP - 100 mmHg ● Maintain the stump pressure – 70mm Hg (Stump pressure <40 mmHg, 21% stroke)
- 25. ARTERIOTOMY ARTERIOTOMY Longitudinal arteriotomy, exposureof the plague Longitudinal arteriotomy, exposure of the plague
- 26. SELECTIVE SHUNT ORROUTINE SHUNT SELECTIVE SHUNT OR ROUTINE SHUNT ● Routine shunting / selective shunting ● Intraoperative monitoring , abnormalities after cross-clamping of the ICA - selective shunt during CEA ● Studies comparing routine and selective shunting - both groups were associated with low stroke rates (routine shunt vs. selective shunt: 0% vs. 2%, p = 0.498) ● We perform routine shunting
- 27. European Society forVascular Surgery (ESVS)
- 28. CAROTID ENDARTERECTOMY CAROTID ENDARTERECTOMY ●Plaque removal – in the sub Plaque removal – in the sub intimal plane intimal plane
- 29. PATCH ANGIOPLASTY VS.PRIMARY SUTURE PATCH ANGIOPLASTY VS. PRIMARY SUTURE ● Patch angioplasty reduces the risk of stroke and restenosis ● Flushing
- 30. PATCH ANGIOPLASTY VS.PRIMARY SUTURE PATCH ANGIOPLASTY VS. PRIMARY SUTURE ● Patches used ○ Biological - Saphenous vein ○ synthetic (e.g., Dacron or polytetrafluoroethylene)
- 31. ● Autologous venouspatch Autologous venous patch European Society for Vascular Surgery (ESVS)
- 32. CEA COMPLICATIONS (NHSL) CEACOMPLICATIONS (NHSL) ● Stroke – 4.3% ● Nerve injuries ○ Hypoglossal - 4.3% ○ Marginal mandibular nerve ● Graft site complications ○ Thigh haematoma - 5.26% ○ Wound infections - 10.53% ● Mortality - 2.4%
- 33. OUR EXPERIENCE (NHSL)- DELAY OUR EXPERIENCE (NHSL) - DELAY ● Mean waiting time (onset to duplex) - 49.74 days ( 3 days - 7 months) ● Duplex to CEA - 20.05 days ( 5 days - 2 months) ○ CEA - maximum benefit within 14 days
- 34. OTHER COUNTRIES (NATIONALREGISTRIES) ○ Norway - 11 days ○ Netherlands - 11 days ○ UK - 11 days ○ Germany - 9 days ○ Sweden – 8 days
- 35. CAUSES FOR DELAY CAUSESFOR DELAY ● Time taken for the investigation ● Time for the patient optimisation ● Infrastructure related
- 36. CAUSES FOR DELAY CAUSESFOR DELAY Time taken for the investigation ●Delay in scanning ○ Non availability of scanning slots ○ Scanned by different individual ●Awaiting computed tomographic angiography
- 37. HOW TO OVERCOME HOWTO OVERCOME ● Establishment of multidisciplinary teams – stroke team Establishment of multidisciplinary teams – stroke team ○ Neurologist Neurologist ○ Radiologists Radiologists ○ Surgeons / neurosurgeons Surgeons / neurosurgeons ○ Anaesthetists Anaesthetists ○ Physicians Physicians ○ Cardiologists Cardiologists ○ Administrators Administrators ○ Team for the post operative care Team for the post operative care ● Protocol Protocol
- 38. HOW TO OVERCOME HOWTO OVERCOME • Delay in scanning • Awaiting computed tomographic angiography • Extended investigations (concurrent co- morbidities) • Dedicated staff for scanning Dedicated staff for scanning • Time for CTA Time for CTA
- 39. CAUSES FOR DELAY CAUSESFOR DELAY Time for the patient optimisation ●Extended investigations / optimisation (concurrent co- morbidities) ●Patient on drugs e.g: Clopidogrel,Warfarin
- 40. HOW TO OVERCOME HOWTO OVERCOME • Extended investigations / optimisation (concurrent co- morbidities) • Patient on drugs e.g: Clopidogrel, Warfarin •Inter disciplinary care •Protocol based approach
- 41. CAUSES FOR DELAY CAUSESFOR DELAY Infrastructure related ●Surgical list ●Staff awareness of the urgency ●Other elective and emergencies
- 42. WORKLOAD WORKLOAD Surgeries Approximate percentage Trauma+ Emergencies 10.9%++ Dialysis access 24.6% Transplantation 18.0% Arterial Bypass 9.5% Aorta 3.3% Venous procedures 24.4% Other 9.2 %+++
- 43. HOW TO OVERCOME HOWTO OVERCOME Infrastructure related •Surgical list •Staff awareness of the urgency •Other elective and emergencies • Dedicated theatre time Dedicated theatre time • Protocol for timing of CEA with administrators and Protocol for timing of CEA with administrators and theatre staff theatre staff (use the experience from the emergency (use the experience from the emergency department) department)
- 44. WORKLOAD WORKLOAD Surgeries Approximate percentage Trauma+ Emergencies 10.9%++ Dialysis access 24.6% Transplantation 18.0% Arterial Bypass 9.5% Aorta 3.3% Venous procedures 24.4% Other 9.2 %+++
- 45. FUTURE DIRECTIONS FUTURE DIRECTIONS ●Establish Establish multidisciplinary team multidisciplinary team ● Institutional protocol Institutional protocol
- 46.