Carotid Endarterectomy (CEA)
What the Examiner Expects
Surgical removal of atherosclerotic plaque from the carotid bifurcation to prevent stroke. The examiner expects you to cite the landmark trials (NASCET, ACAS) and know the indications: symptomatic carotid stenosis ≥ 50% (TIA or stroke ipsilateral to the stenosis within 6 months) or asymptomatic stenosis ≥ 60–80% in patients with reasonable life expectancy and low surgical risk. The procedure involves clamping the common, internal, and external carotid arteries, performing an arteriotomy, developing the endarterectomy plane, removing the plaque with a smooth distal endpoint, and closing with a patch (Dacron or bovine pericardium).
Key Examiner Focus Points
- Indicated for symptomatic stenosis ≥ 50% (NASCET) or asymptomatic stenosis ≥ 60–80% in selected patients
- Symptom within 2 weeks: urgent CEA provides maximum benefit (CREST-2 criteria)
- Patch angioplasty closure reduces restenosis vs primary closure
- Shunt use varies by surgeon — mandatory if stump pressure < 40 mmHg or EEG changes
- Postop stroke, cranial nerve injury (vagus, hypoglossal, marginal mandibular), and neck hematoma are key complications
Common Curveballs
EEG shows changes after carotid cross-clamping
Cerebral hypoperfusion. Place an intraluminal shunt (Javid or Pruitt-Inahara) to maintain cerebral blood flow during the endarterectomy. Some surgeons routinely shunt; others selectively based on EEG, stump pressures, or awake testing under local anesthesia.
Postoperatively, the patient develops a new neurologic deficit (contralateral weakness)
Postop stroke — likely thromboembolic from the endarterectomy site. Obtain emergent CT head (rule out hemorrhage). If ischemic, consider emergent re-exploration with thrombectomy at the endarterectomy site. Time is critical — return to OR immediately rather than waiting for imaging if the deficit occurred in the recovery room.
Patient develops ipsilateral tongue deviation after CEA
Hypoglossal nerve injury (CN XII) — the nerve crosses the ICA and ECA high in the neck. Usually a traction injury that recovers over weeks to months. Intraoperative identification and protection is key. The vagus nerve (CN X — hoarseness) and marginal mandibular branch of CN VII are also at risk.
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