About a decade ago, I was at a meeting and had a colleague discussing carotid stenting and showing photos of traditional CEA incisions, which were 4 to 6 inches in length and left an unslightly scar, which got me thinking that he was right that making a huge incision to treat a short segment of disease didn’t make sense. Seven or 8 years ago I began using this technique in earnest, to decrease the length of the incision, and improve the cosmetic result.
What are the preliminary results of your research?
I’ve done this procedure in over 200 patients and only presented results on 42 patients who I’ve studied prospectively. The technique involves identifying the carotid bifurcation with a b-mode ultrasound and marking the bifurcation on the skin, and then making a 2.5 cm incision in the neck centered over that mark. It gives standard exposure of the carotid artery.
There was one patient who, out of the 42, required enlarging the incision because of the need to treat more proximal disease, which had not been identified preoperatively. There were no strokes, no deaths, and no MIs in that group. There was one temporary cranial nerve injury and the majority of patients were discharged in less than 24 hours after their procedure. All but one patient were treated with eversion carotid endarterectomy and one patient required a shunt and had a standard endarterectomy with a patch.
How are patients handling the after-effects of the procedure? Do follow-up visits show promising results?
The advantages for patients include less pain and less swelling. We now operate on patients who are fully anticoagulated and it causes less bleeding with a smaller incision and less tissue trauma.
The technique is safe; it allows for a complete endarterectomy despite a small incision and does not increase the risk of cranial nerve injury and provides a superior cosmetic result.
Were there any side effects associated with the procedure? What limitations did you encounter?
The limitations are that preoperative imaging is important to exclude patients who have disease that extends far into the common carotid artery; the other limitation is that given the small size of the incision, it can be challenging to place a shunt, technically feasible but a bit more challenging. Finally, this is probably not a good technique used under local anesthesia. The technique that I use is under general anesthesia with EEG monitoring.
What is the next step for your research? Do you plan to continue with more patients?
I’ll continue to evaluate patients in a prospective fashion. We have, in the latter part of currently recorded experience, started evaluating all patients with an NIH stroke scale pre- and postoperatively. All patients will now have this and it has become a standard in our practice. I believe that independent evaluation should be used for all patients.
Dr. Timothy M. Sullivan is the chairman of vascular and endovascular surgery at the Minneapolis Heart Institute and co-director of the Vascular Center at Minneapolis Heart Institute at Abbott Northwestern Hospital. He received his medical degree from Northeastern Ohio University College of Medicine, Rootstown, Ohio completed a residency in General Surgery at Wright State University, Dayton, Ohio. Dr. Sullivan completed a fellowship in Vascular Surgery at St. Vincent Medical Center, Toledo, Ohio and The Cleveland Clinic Foundation, Cleveland, Ohio.