Surgical intervention in the area of

carotid stenosis Classical carotid

endarterectomy case report
Kallob.Mohammed1,Asad.Asad2, Yasser Elkhaldi3, Sheikh.Abdelrahman4
1Department of vascular surgery, EGH, Gaza, Palestine, 2General surgery department, EGH, Gaza,

Palestine,3Department of anesthesiology, EGH, Gaza, Palestine, 4 Faculty of medicine, Islamic

University of Gaza, Gaza, Palestine.

Stroke is defined as a cerebrovascular accident with the development of

persistent symptoms of central nervous system, the nature of which
depends on the location and extent of the damaged area of the brain.
According to the World Federation of Neurological Societies, the world
each year is recording at least 15 million strokes. In the U.S., stroke is
the third leading cause of death each year 500,000 strokes. From these
strokes and its complications in the U.S. die 150,000 people a year.
80-85% of Ischemic strokes is caused by atherosclerosis of the arteries
of the head and neck, affecting small cerebral arteries due to
hypertension, diabetes or cardiac emboli.
Mortality after an ischemic stroke is 20% within the first month and
about 25% for the first year. 6 months after stroke disability occurs in
40% of survivors.
Medical treatment of transient attacks and small strokes practically
protects patients, and 52-55% within 3 years comes a large cerebral
infarction, however the incidence of recurrent strokes or transient
ischemic attacks within 5 years in patients operated for atherosclerotic
vascular lesions of the neck is 1-3%.
In 1953 the first case of trombendarterectomy has been successfully
applied in the defeat of the carotid artery. M. DeBakey, Houston, Texas.
In 1984, Kieny R. c et al., performed carotid endarterectomy by eversion
technique

Case presentation
70 years old male patient was admitted to the department of
vascular surgery in EGH complaining of recurrent transient
ischemic attacks, On his medical history there was hypertension,
dyslipidemia, DM and Severe coronary artery disease (CAD) Post
cabbage in 2010. The patient was on clexan Forta 200 u daily.
The patient underwent duplex US of carotid vessels that showed
bifuricational and right internal carotid artery stenosis of more
than 80% and the results was confirmed by CT angiograph.
The plaque was found to be calcified with ulceration and micro
thrombi (Type V), the surgery was decided to relieve patients
symptoms and to prevent further attacks and brain Ischemia.
Intra-operatively, Classical carotid endarterectomy was done
without temporary shunt due to high tolerance of brain ischemia
(pre-operative study)
Total blood loss was 200 cc, total operation time was 1hr 30 min.
The patient was extubated in the OR, with normal superficial
reflexes and transferred to the department in a good general
condition.
Follow-up visits at 1 and 24 months after surgery were unremarkable.
Duplex US was done in the last visit and showed no stenosis.

Figure.1 Exploration of internal carotid artery

Figure.2 plaque after removal

Discussion
160,000 operation of Carotid endarterectomies are performed
each year in U.S., in contrast, Stenting and balloon angioplasty
(according to different countries) accounts for about 15-25% of
total number of cases with carotid stenosis.
Long-term results of surgical treatment are far superior in their
effectiveness to the carotid angioplasty method zone.
Color Duplex ultrasound scanning is considered to be the main
method for detection of significant stenosis in the carotid region
(Any stenosis > 50%, Sensitivity 98%, specificity 88%), (Any
stenosis > 70%, Sensitivity 90%, specificity- 94%).
Surgical intervention is indicated in Stenosis> 70%, Embologenic
stenosis 50-69%, Acute thrombosis of the ICA and if the plaque is
type V.
Medical intervention is indicated for small and medium stenosis,
that are not causing recurrent ischemic attacks and upon the
occurrence of ischemic stroke

Conclusion
Therapeutic treatment should be carried out in conjunction with
surgery to achieve the best results as the Long-term results of
surgical treatment substantially improves the quality of life and
health of patients over a long period.
Screening by duplex US is recommended for all patients with high
risk for developing carotid stenosis especially those over 60 years,
smokers, hypertensive and diabetics patients.

References
Carotid Artery Disease, Stroke, Transient Ischemic Attacks (TIAs), Vascular Web, November
2010.
Improvement in accuracy of diagnosis of carotid artery stenosis with duplex ultrasound scanning
with combined use of linear array 7.5 MHz and convex array 3.5 MHz probes: validation versus
489 arteriographic procedures.
Leonardo G1, Crescenzi B, Cotrufo R, Tecame S, De Santo LS, Della Corte A, Fratta M, Cotrufo M.
J Vasc Surg. 2003 Jun;37(6):1240-7.

Validating common carotid stenosis by duplex ultrasound with carotid angiogram or computed
tomography scan.
Matos JM1, Barshes NR2, Mccoy S3, Pisimisis G2, Felkai D3, Kougias P2, Lin
PH1, Bechara CF4.
J Vasc Surg. 2014 Feb;59(2):435-9. doi: 10.1016/j.jvs.2013.08.030. Epub 2013 Sep 29.

Dawson DL, Zierler E, Strandness DE Jr, Clowes AW, Kohler TR. The role of duplex scanning and
arteriography before carotid endarterectomy: a prospective study. J Vasc Surg. 1993;18:673683.
Faught WE, Mattos MA, van Bemmelen PS, Hodgson KJ, Barkmeier LD, Ramsey DE, Sumner DS.
Color-flow duplex scanning of carotid arteries: new velocity criteria based on receiver operator
characteristic analysis for threshold stenoses used in the symptomatic and asymptomatic
carotid trials. J Vasc Surg. 1994;19:818-828.