Risk-benefit analysis for CEA

• Surgery indicated if risk of stroke (pre-op) >>> risk of complication

Pre-op risk

• Population risk: 2%
• Asymptomatic stenosis risk: 2%
• TIA risk: 20%

Peri-op Risk

• stroke: 3-5%

• Any complication: 2-3%

• Decision Making Flow Chart

• Asymptomatic stenosis: 2% risk of stroke → No Surgery

• Complete Occlusion → No surgery

  • Alternate route has dilated. Risk hyperaemia of the brain with re-perfusion.

• Symptomatic stenosis (>50%)

  • BMT (ASA)
  • Elective Surgery

• TIA

  • BMT (DAPT x 21 dys)
  • Surgery ****within 14 days to prevent stroke

Specific Complications

• Peri-op stroke rate 3-5%

• MI risk 2-10%, but usually clinically silent (little pain and rapid recovery)

• Risk of nerve injury ~5% (almost always transient)

  Nerve	Presentation
  CNVII Facial Nerve (mandibular branch)	Perioral weakness, drooling (r/o stroke)
  CNIX Glossopharyngeal nerve	Inability to swallow
  CNX Vagus nerve	Hoarseness
  CNXII Hypoglossal nerve	Deviation of tongue to affected side
  Sensory nerve injury (GAN)
  *Vascular surgeon don’t try to ID this	Decreased sensation/paresthesia along jaw and earlobe
  Sympathetic nerve injury	Horner’s syndrome (ptosis, miosis, anhidrosis)

Contraindication

100% stenosis, asymptomatic diseases, cannot tolerate procedure