Vascular Surgery Patient Experiences Severe Stroke During Procedure

This case involves an 65-year-old male patient in a good state of health who underwent a left carotid endarterectomy. Pre-op imaging had indicated moderate stenosis in the common carotid artery and mild-moderate stenosis in the left subclavian artery. His case was complicated by new findings of neurologic deficits namely, the inability to move his right upper and lower extremities which necessitated immediate re-operation prior to exiting the operating room. Before the surgery, he had been very active and operated a successful roofing business. Post surgery, his quality of life has been significantly impacted as he can no longer run his business due to being a high fall risk, aphasia, and memory and cognitive deficiencies.

Question(s) For Expert Witness

1. Do you routinely perform carotid endarterectomies?

2. In your experience, what are the indications for performing carotid endarterctomies?

3. Which studies do you utilize in the preop work up and what is your threshold for operating?

Expert Witness Response E-006875

Carotid endarterectomy (CEA) is a procedure meant to reduce the risk of stroke long-term. That being said, there is an operative risk of about 2-3%. Carotid disease is divided into symptomatic and asymptomatic. Everyone agrees that CEA should be performed for symptomatic patients with >50% stenosis due to the fact that it decreases your 2 year stroke risk from 26 to 9%. However, there is no consensus for asymptomatic disease. Older studies show an absolute 5 year stroke risk reduction of 5% (from 10 to 5%). However, that was before statin medications. There is an ongoing trial called the CREST II trial which is meant to answer this question. Many believe that there is no benefit to surgery for asymptomatic disease UNLESS there is progression of stenosis despite maximal medical therapy, or there is echolucent plaque on ultrasound. From the synopsis about the case, it seems like this patient never should have had surgery (assuming he was asymptomatic and that he had only a moderate stenosis). I routinely perform carotid endarterectomies. I have not had a patient develop a stroke after a carotid endarterectomy, although I was involved in a similar case during training. I have both lectured and published on this topic. I am currently Associate Professor of Surgery at a major medical university as well as Fellowship program director in the division of Vascular Surgery and Endovascular surgery.