What are the indications for a carotid endarterectomy?

Carotid endarterectomy is indicated in symptomatic patients with symptoms suggestive of ischaemia in the carotid territory (TIA or Amaurosis Fugax) who have a major degree of carotid stenosis (between 70% and 99%). This is based on results from the European Carotid Surgery Trial (ECST) and the North American Symptomatic Carotid Endarterectomy Trial (NASCET). Patients who have symptoms suggesting insufficiency of the vertebro-basilar circulation are not included.

There is currently a randomised clinical trial, which is looking at asymptomatic patients with carotid stenosis (the Asymptomatic Carotid Surgery Trial).

What are the clinical presentations of ischaemia of the carotid and the vertebro-basilar circulations?

• Carotid: contralateral hemiparesis, hemianopia, hemisensory disturbances as well as dysphasia (dominant hemisphere) or visuospatial apraxias.

• Vertebrobasilar: Vertigo, diplopia, dysphagia, dysphonia, nausea, vomiting or ataxia

What pre-operative measures should be taken?

• To establish the diagnosis and grade the stenosis, duplex scanning is the investigation of choice in most centres. Patients were previously investigated using IADSA; but this itself carries a 12% risk of stroke. Some centres are now using magnetic resonance angiography (MRA) as an alternative. The patient will also require a CT scan of the brain to establish pre-operative infarcted areas.

• Anaesthetic assessment and informed consent.

• The patient should have an intravenous line and an arterial line in situ.