Transcript

- Hello ladies and gentlemen, and thank you for joining us for another session of the AANS Operate Grand Rounds. We're privileged today to have with us, Dr. Bob Harbaugh, from Penn State Hershey Medical Center. He will be talking to us about pearls of performing carotid endarterectomy. Bob, I wanna thank you for joining us, and we're very excited to listen to your comments.

- Well, I would like to thank Aaron and AANS for setting this up, right. This is a great opportunity. So without further ado, we'll just move right into the slides. And this is going to be a very quick, step-by-step review the technique of carotid endarterectomy using regional anesthesia, which is how I do it. This is an observatory disclosure slide showing that I'm adequately bought and paid for, but none of these represent a conflict of interest with the present topic. A successful carotid endarterectomy really starts with the preoperative care. When you see the patient, you are in the hospital or in the office, make a detailed explanation of the procedure. Exactly what's gonna happen step-by-step really goes a long way to laying the patient's anxiety. Make a point of having the patients take their usual medications up to, and on the day of surgery. We don't wanna disrupt their normal routine. I have all of my patients on aspirin and Plavix preoperatively, and I'll start them a few days before the surgery if we have that opportunity. That they need a loading dose of Plavix. We'll give them a 300 or 600 milligram, loading dose the night before the operation is, as needed. Since doing that, I've noticed having a decrease in cardiac complications, but also a decrease of the perioperative stroke rate. So I think aspirin and Plavix, really do have a place. We use noninvasive blood pressure monitoring only. A single IV, we don't use arterial or central venous lines, urinary catheters or compression stockings. We try to make this as minimally disruptive procedure as possible. The anesthetic technique, I will often do my own blocks. Sometimes the anesthesiologist would do their block depending on the anesthesiologist. It's a very simple procedure to do. It's a superficial cervical block. And the way I do that is just to pick or point to a one third and two thirds, the way from the ear to the chroticle and inject a large volume of half percent lidocaine posterior to the sternocleidomastoid muscle. And it gives you really a few block that's a very nice superficial block. And it can be done immediately in about 45 seconds to a minute, then I'll usually supplement that a long the incision line. We use minimal sedation. I think particularly with the elderly patients, it can give them a little sedation they get confused, and that can be more of a problem. I like have a very awake patient. A patient is positioned supine, head on a gel ring, turned slightly contralaterally, and it's really important to make sure the patient is comfortable, yet they need to have their knees elevated. If they have arthritis you can do anything you can to allow them to lie still for the procedure. We do put a piece of tape across the fore head to hold the head in place. It's just a natural reaction for someone to turn his or her head to you if you speak to them and this keeps them from moving their head. We give them a little squeak toy in their contralateral hand. That's our high tech monitoring equipment to allow us to check motor function during the case. And we leave the face completely exposed so the patient doesn't feel claustrophobic at all. And we'll be demonstrating this in the movie. I use a transverse incision for cosmetic reasons. We put it in a dominant skin crease and usually stop about a centimeter or so from the mid line. And the lateral line that goes to one to two centimeters, lateral to the angle of the mandible as is illustrated here. And usually our curve is cephalad lateral to skin crease. We divide the skin with the scalpel and then switch over to the monopolar, and then use the monopolar to dissect through the platysma muscle. We'll cut through the transverse cervical nerve to try to spare the greater auricular nerve And you do need to warn the patient, an awake patient about muscle contraction when you use the Bovie to divide the platysma. We then find the anterior border of the sternocleidomastoid muscle. And again, I used the monopolar. And if you get in that plane, just adjacent to the muscle and you can go anteriorly on the sternocleidomastoid muscle to the hyaloid superiorly to the diagnostic, to get really excellent exposure. And we go down to close to the carotid sheet, using the monopolar. At that point, we then switch our sharp protractors to blunt retractors to retract the muscle. Use DeBakey forceps, and switch over to using the bipolar and metzenbaum scissors for dissection. You wanna avoid posterior surface of the sternocleidomastoid muscle because of the accessory nerve and just stay on the anterior circles. Often you're running juggler chain link nodes, as you do the dissection. And when you do that, you always dissect medial to the lymph nodes. And that's where the blood supply comes from. It'll take you down to the juggler vein, and then you can retract the nodes with the internal jugular vein. It's not necessarily most times they actually removed them. The next step is to identify the common facial vein that could need to be divided after it's ligated. And that's often a good marker for the level the carotid bifurcation as well. So this just shows the canotial vein going cross. You'll see how we divide this with log acres, with live equips and then divide it. And once you're in the carotid sheath, then it's easy to start to move up and down in the carotid sheath through carotid. If you need to divide the contation vein, you want to make sure particularly it's highlighting, that the top cranium nerve is not on the back wall because you can injure the hypoglossal nerve and dividing this if you don't do a good circumferential resection. We give heparin, usually about 5,000 units of heparin intravenously before starting dissection in the carotid sheath. And usually when you start the carotid sheath dissection, you do have to give a little extra lidocaine because of the sympathetic fibers. Lateral retractor blades are then placed between the common carotid internal jugular vein so you retract the juggler laterally. Medial retractor blade are more superficial. You don't wanna get into the medial musculature 'cause you will have a chance of hurting the recurrent laryngeal nerve and giving yourself a lot of problems and the patient, a lot of problems post-operatively. I use a cloward retractor with smooth blades. One gets hooked under on the highlighted muscle, the other up above the hypoglossal nerve, up and on the digastric muscle. And again, you'll see this in the video. Once we're in the carotid sheath, it's bipolar only. You can dissect medially along the common carotid artery and up to the external carotid superior thyroid artery. And then I do a circumferential dissection around all of the vessels. I know a lot of people don't, but I think it allows you to help elevate the carotid out of the incision, gives you some really good distal exposure. And if you do it carefully, you don't have to worry about injuring the superior laryngeal nerve which runs behind there, but you have to stay right on the carotid. I think one of the keys to avoiding complications in this operation is to make sure you have adequate distal exposure. And one way to do is to dissect lateral to the hypoglossal nerve, the hypoglossal nerve hooks around the artery to the sternocleidomastoid muscles, so that we'll walk them and and divide that there are small veins lateral to the hypoglossal nerve that need to be coagulated and divided. And we're often divide the answer that allows the hypoglossal nerve to add up. Once we're sure we have adequate exposure, we put vessel loops around the common carotid, external carotid, and internal carotid. The one in the common carotid goes around twice and we use a Rummel tourniquet, which will be used to hold a shunt in place If the shunt needs to be used. I can put a patty beneath the carotid bifurcation to bring the carotid out of the depths and make sure we have a shunt available. We use aneurysm clip, starting with the small aneurysm clip on superior thyroid artery, and then this to the internal carotid artery as far distal as we can get it. We use atraumatic vascular clamp on the common carotid artery. And you put that as far a proximal as you can get it. And then an aneurysm clip on the external carotid up to, just proximal to the bifurcation. Occasionally you'll find the ascending pharyngeal artery coming up right at the bifurcation. And you use a small clip on that as well. The arteriotomy is a stab incision through the vessel wall and plaque to the common carotid lumen. And you make that small. If there is brisk bleeding, you know that you have to really adjust your clip and you can control that small incision with the, you know, your DeBakey forceps. And if there is bleeding you just check your clamps and clips, look for an ascending pharyngeal artery probably if the other clips look okay. Then extending incision distally along the internal carotid, making sure to stay in line with the internal carotid and not allow the plaque to push you in the bifurcation. The residents who may start to do this, that's a common problem where the plaque seems to try to try and push you to the bifurcation. And that really makes a closure much more difficult. So you wanna avoid that at all costs. We will extend that incision and you can internal carotid beyond the end of the plaque to allow you to get a very nice distal removal of the plaque, and then avoid spiraling the incision. You just wanna stay straight on the internal carotid. And then we also extend the common carotid arteriotomy a little bit proximally. We you remove the plaque, and usually once you've opened the vessel you'll see an area where the plaque starts to separate from the vessel wall. And then we use a little woods and nuts and dissected to go both proximally and distally, starting from that area of separation. And the plaque will almost always feather out distally along the internal carotid. It's been many years since I've had to put packing sutures distally. You should, if you have adequate exposure, be able to get that plaque to feather out. I think the key to this operation is really meticulous plaque removal, peelings, and quality blur. If you knew that, you know, whether you patch or don't patch on or don't shunt, probably doesn't make much difference, but there's plaque removal and the closure that is very important. The proximal part of the plaque, you transect sharply, you could follow that plaque back to the aortic valve if you wanted to. So you have to pick a spot where you say, "Okay, this is far enough," and sharply transect it. We irrigate the arteriotomy site with heparinized saline inspected with magnified vision with loops. I do this procedure with loops not the operating microscope. And then with the 5-0 or 6-0 one in Prolene suture. And I usually start distally internal carotid and then go distal to proximal. You don't want to go proximal to distal because if you end up with a doggy, it's much harder to deal with that internal carotid than it is in the common carotid. And some people will start either end and move toward the middle, which I think is perfectly fine. The stitches at the internal carotid end, the distal end of the incision need to be very precise. And I a millimeter deep and a millimeter apart, and it's always intima to intima. As you move down into the common carotid artery, you can put the sutures a little deeper, a little farther apart. If the patch graft is needed, we'll use Hemoshield. There are rough and smooth surfaces to the Hemoshield, and you want the rough surface on the outside. And when you do a patch graft which is something less than 10% of our patients, we'll use a double arm prolene with an inside out approach on the patch. So two needles through the very tip of the patch, and then out through the vessel, tie that down and run one down the each side of the patch, which gives you a very nice closure. Before you complete your closure, it's important to check for backflow. And you should have brisk backflow, if you don't, there is a problem and you need to reopen the vessel and evaluate what's going on. If you get out this backlog and reapplied the internal carotid clip, but don't suck it out your vessel. You do wanna fill that muscle up with blood, not with air. So backlash, put your clip back on then complete your closure. After the closure's completed, I think it's also a good idea to again, take your internal clip up. There's a little bit of air left in the vessel. Sometimes you can actually see it sort of bubble out along the suture line and then reapply internal clip. Next, you take the external clip and the common carotid cramp up and allow at least 10 seconds for any debris to flush through the external system. And then finally, we move internal carotid clip. And this is all done with the patient awake. If during cross clamping they develop a deficit, you can put a shunt in, but you wanna make sure that the patient's examined rather frequently after reestablishing internal carotid flow. And of course, additional sutures is needed. If you have any bleeding, you have to reopen the vessel. Occasionally, we apply shunts with the regional anesthetic. The incidence of shutting was only about 4% in my series, but we're always prepared to have the shunt available in the room before we occlugate internal carotid. We check running neurological changes once the internal is acquainted. If ischemic symptoms do occur, then usually we ask the anesthesiologist to bring the blood pressure up a little bit. And then I'll go ahead and remove the plaque before replacing the shunt. I think it's just much easier to get the plaque out without the shunt in place. And there's no emergency about putting the shunt in in 30 seconds. So we'll take the plaque out and then go ahead and use a short shunt, three or four millimeter diameter, usually with three, that's placed into the common carotid artery secured with the Rummel tourniquet. You then flush it briefly by opening the basket or cramp for a second, and then place the distal part of the shunt into the internal carotid artery. And you can advance that, take off the aneurysm clip and it's got a little acorn into it that prevents back flow. It's a very nice, simple shunt to use. Then you can remove the common carotid vascular clamp and reestablished flow. And once you've done this a few times, it usually goes very smoothly and doesn't take a lot of time. If you use a shunt, the rest of the procedure, quarter here is as we talked about before, and when you get down to maybe having two thirds or three quarters of the vessel closed, you wanna make sure you blocked enough open arteriotomy to get the shunt up. Clamp the common carotid. Loosen Rummel tourniquet. Remove were the common carotid end of the shunt, and then pull it out of the internal carotid. You'll get some back weighing from the internal carotid. You can put a aneurysm clip on that and continue with your closure. And hemostasis is crucial. I think as previously noted, I do all of these on aspirin and Plavix, but we have not had problems with wanking the toes, but we're really meticulous about the hemostasis. So we irrigate at any point. Bleeding is coagulated with the bipolar. I use flow seal, which is really wonderful stuff for oozing. And then we do reverse the heparin with protamine at the end of the procedure, I put platysma and sub-cuticular absorbable sutures in, usually 3-0 micro. And then close the skin with Dermabond. So it's closed immediately so the patient can shower. the suture through a move, et cetera. We mobilize the patient as soon as they're out of the recovery room, and we'll get them out of bed and recovery room to go to the bathroom if need be. They'll get no blood pressure checks or two to four hours overnight. Hypertension, postop is treated aggressively. Hypotension is not a problem usually, and doesn't require aggressive treatment. We'll give the patients a little bit of extra volume, but almost never use pressures. Someone who is hypotensive will have an EKG check to make sure that this isn't a cardiac problem, but it really is, and almost everybody goes home the next day. Postoperatively again, we wanna mobilize the people as quickly as possible. And that I think is the key to making this minimally disruptive procedure. And I believe that, you know, carotid endarterectomy can be as minimally invasive as endovascular treatment if done correctly. We send them home the next day on aspirin and Plavix. They do a clinic visit in six weeks. And if they're doing well at six weeks, I'll tell them to stop the products at that point and just continue with maybe a aspirin per day. And I see everybody back at six months, a Duplex study has done it at six months. Obviously, if they have any problems in the interim, I instruct them to call. And that's the end of the slide presentation. So we just mark the posterior board of the sternocleidomastoid muscle here to get an idea of where to put the blocking. And the block goes posterior to the sternocleidomastoid. And if have the patient snip, you should their Glock and a good way to show it. And then this is the little squeak toy in the contralateral hand. So we're doing a right carotid, it goes in the left hand. And I'll put a little piece of tape on there in case the patient relaxes during the procedure. You don't want it to fall out of his or her hand. So put I little bit of tape just to hold the toy in place. And so the patient is wide awake. And is a little extra lidocaine being put in a long incision, and see it's a transverse incision. And we leave the patient's space exposed so they're not claustrophobic. There's the initial standard incision in the skin crease and placement of the retractors. And these are sharp tooth retractors for the scan and platysma. And you see the electric cautery is used to divide that platysma muscle. Now we're coming down looking for the common facial vein, which is going to be right here. Now, as you get down to the carotid sheath, it's often a good idea to give a little extra lidocaine, because it's hard to block the sympathetic fibers that run along with the carotid, with the superficial or even a deep block. So here's a good example of how the hypoglossal nerve can be sitting right behind the common facial vein. Here's common facial vein. There's hypoglossal. And if you're not careful to do a circumferential dissection, you can certainly injure the hypoglossal inadvertently. So we're dissecting that facial vein frig, and that of he laryngeal with a couple of little clips. And I usually put two little clips on the juggler side and one little clip on the other side of the vein, and then just divide it between the little clips. I use them instead of ligature, just 'cause it's a little quicker. This is showing it's coming up lateral to the hypoglossal nerve. So you can see, if you want to get good distal exposure. Dissecting in the carotid sheath here. And these are now blunt tooth retractors that are being used at this point so we don't injure the sternocleidomastoid muscle. So you're starting to see, this is the section in the carotid sheath. Bifurcation is going to be about here. And if you get in the right plane, this goes very quickly. So we can dissect the carotid at very little time. So bifurcation is coming end near here. And we'll be looking for superior thyroid artery soon. Okay, so this hypoglossal nerve. This is common carotid in the bifurcation. This is the cloward retractor, an old cloward retractor. I talked about with the smooth blades. And so we'll put the superior blade just above the hypoglossal nerve and the inferior blade in omohyoid. And if we opened that we get good up and down exposure even with the transverse incision. Yeah, this is certainly inadequate exposure distally. So we're gonna have to go above, where we are now. The best way to do that is to come lateral to the hypoglossal, which is what we're doing now. Sorry, my big hands in the way there. We had one of our residents during the filming, so I blame it on the resident as usual. But here's the answer coming up to the hypoglossal, and we're coming out lateral to the hypoglossal nerve and we'll see how we get a really nice distal exposure by doing that. Block the necessary to get a little extra lidocaine into the carotid sheath as you dissect around the carotid. I did once inject lidocaine into the internal carotid, and the patient promptly had a seizure. Now, it's very impressive it didn't last very long. No, a long time melopixine. Thankfully, she didn't remember it. Okay, so hypoglossal coming here. Readjusting the retractor. Again, if you get lateral to this hypoglossal nerve, you can come well up on the internal carotid. One advantage of the regional anesthesia is not having the mandible depressed by having an endotracheal tube going through the mouth. Depressing the mandible even a little bit really does limit your distal exposure. And high carotid bifurcation is not a concrete indication to a regional anesthetic. If anything, I think it's somewhat easier to get distal exposure without having an endotracheal tube to fight with. So you see the superior thyroid artery being dissected through right here. Bifurcation being defined a bit better. And again, wanna make sure you get good distal exposure of that internal carotid, because that's where I can people get in trouble, not being able to get beyond the plaque. This was a fairly hot high bifurcation. And in that case, you know, you usually have plenty of common carotid vessel to deal with, but you have to work a little bit harder to get the internal exposure. As I noted during the slides, I do dissect circumferentially. So we'll go behind the carotid. Some people don't because of the concern about the superior laryngeal nerve, but if you stay right on the vessel you won't not injured at nerve. And I think it does give you a really nice exposure and allows you to lift the carotid up and out of the depths of the incision. So it makes the surgery a little bit easier once you get the circumferential dissection done. Now, you'll notice it's only bipolar cautery that's used now. So we're going to set behind the external carotid here, and we're gonna put a vascular tape around that. Okay. So resuming the vascular tapes been placed around the external carotid and we'll put, usually a mosquito clip on that. We do place a tape underneath the internal carotid, but we just allow it to lie there. And then we put the tape around the common carotid twice, and we'll use Rummel tourniquet on that. And that would be used to hold the shunt in place if we need a shunt. So this is the Rummel tourniquet going on, you'll see that in a second. And the idea is you wanna keep all of this stuff out of your way. We try to make sure we don't get a lot of stuff in the way of doing the surgery. There's that patty underneath the carotid to help lift it out of the depths a bit. And now we're gonna put a little curve clip on the superior tyroid artery, just to get that out of the way. And you place this so it lies down flat, and isn't gonna catch your sutures. Now the next step would be to put an internal carotid aneurysm clip on, and you want to do that as distally as possible. So we can pull the internal carotid down by grabbing the admintasha, and make sure this is well past the plaque. We're now occluded. And we'll ask our anesthesiologist to do a brief neuro exam on the patient. Ask a patient to squeeze the toy in the contralateral hand, and talk to us, and we do that every couple of minutes. So another clip on the external, and we've already clamped the common carotid distally here using this atraumatic vascular clamp. And then make a stab incision in the common carotid. And sorry, my hand was in the way. And we've made this incision now, starting from our stab incision going well distally, staying out of the bifurcation. I mean, see, this is a really ugly plaque with a relatively fresh intraplaque hemorrhage. And we're looking for that spot where the plaque starts to separate from the vessel wall. We've now gone distally and had the plaque feather out. And once again, you can almost always get the catheter out distally. And then approximately you take it down to where there's no longer any thick plaque and then use a Joseph scissors to sharply transect the plaque at that point. So now you have the plaque creed up at the internal carotid end and at the common carotid end, and then we will simply take it out on the external by dissecting along the plaque. And this is what you should see. You should see it very nice, smooth vessel internally, inspect this, take the extra time, make sure there's no free floating debris. Look up the internal which is here. There's a middle ring forceps that are occasionally helpful, but you wanna have a really a perfectly clean vessel before you start to close. So now we placed a 5-O suture in this case distally and the internal carotid, and a millimeter deep and a millimeter apart going distally to proximally and nice intima to intima closure. And this is checking for backflow. So we've taken the clip off, you know, make sure there's really brisk backflow. Then we placed that clip but don't suck out the blood, put another suture and closure, and now the clips have been removed and we're gonna irrigate this, make sure that everything is perfectly dry and put some close seal behind the vessel and over the arteriotomy line and then irrigate that way. Maybe take the extra time to make sure that the homeostasis is perfect, the asprin and products are not a problem. Then I'll just put usually about three sutures in the platysma to line things up. And then we put subcuticular sutures in the skin and after the subcuticular sutures are placed, we'll go ahead and move some Dermabond for the final skin closure. So that's what the subcuticular sutures in place, and then wash off the neck well. And go ahead and put the Dermabond on that way the patient can shower and shave. Do everything, right. That's the Dermabond skin adhesive. And this incision really just disappears. So there's the plaque showing a very ugly pack with intraplaque hemorrhage and you feel like you really accomplished something when you take one of those out. And I believe that's the end of the movie.

- Thank you. Well, I thought we can sort of create a discussion next, Bob, if that's okay with you, I'm gonna go ahead and bring up my talk and review further details as you see fit.. These are my disclosures. None all of which obviously, interferes with the discussion. I know this is a technical session. However, let's just briefly review the indications. The guidelines say the carotid endarterectomies for patients with a surgical risk of less than 3%. That means the surgeon has to know his or her own risks, as well as the medical risks on the patient, and their life expectancy of at least five years. This is the guideline for asymptomatic patients. We're not going to go through all the, you know, studies that have been done within the past 20 years in terms of establishing the efficacy of the carotid endarterectomy. But we know this is a procedure that is efficacious and has really stood the test of time. Ipsilateral carotid endarterectomy is acceptable for stenotic lesions more than 60% with or without anti-platelet therapy. Again, that's for asymptomatic patients. And then endarterectomy is also beneficial for symptomatic patients, obviously 70 to 99% severe stenosis with evidence of amyloidosis, few jacks or TIAs or minor strokes. And, you know, the recent controversy obviously, is the CREST study. And the final sort of result of that study was first of all, establishing again, that endarterectomy is a great surgery. However, we found that the younger patients had fewer cardiovascular events with an implant while the older patients had fewer events with this surgical options. And I wanted to ask your opinion, what are your thoughts about the CREST?

- Yeah, CREST is one of a series of randomized studies that have shown back that surgery over stenting in regards to reducing stroke risk and reducing mortality. In CREST, if you add in the cardiac morbidity, the results with surgery and stenting are equivalent. However, if you look at the quality of life issue, since even minor strokes are more disabling than the cardiac events, there's also a statistically significant benefit in CREST for quality of life. Again, favoring endarterectomy over angioplasty and stenting. In fact, if you look at CREST, the two things in CREST, that favor angioplasty and stenting, are a lower risk of cranial nerve injury, statistically significant. And a lower risk of a cardiac event is statistically significant. You looked at the statistically significant differences, favoring endarterectomy includes preoperative stroke, stroke at two years, all stroke and death two years. And there are a number of things that are statistically in favor of endarterectomy because of the way the CREST was designed, including the cardiac events. It was reported as stenting was equivalent endarterectomy, but I think if you really delve into that study, that's not the case.

- Okay. Thank you. I agree with you. Really endarterectomy has stood the test of time. It's a great operation, nobody can argue with that. And it does, you know, improve the health of our patients. Let's talk about some basic controversies. Would you patch or not patch with HEMO-SEAL? You know, I trained at Mayo clinic, and Sundt strongly believed in patching. You know, he's big study. However, as I have practice more, I have found that, that you gotta be selective who you patch, who you don't patch. And I think of being a selective in terms of doing that, it's probably more helpful. It seems like you only patched 10% of your patients, which is good because it really increases the length of the operation. If you do need to patch someone, there's no need to do it. How long would you wait after a patient has a minor stroke? Is a month, enough or six weeks or three months? May I ask your opinion?

- Yeah, actually, if it's a minor stroke, I don't wait. I think that that question was evaluated in NACIT and in NACIT if you waited six weeks, the risk of another ischemic event during that six week waiting time was much higher than the risk of exacerbating the stroke or converting a bland stroke to a hemorrhagic stroke, while doing the surgery early. So when someone has a good surgical candidate, who's had a completed stroke, I will go ahead at the first opportunity to do the endarterectomy. And I think if you watch the blood pressure meticulously, post-operatively, don't allow the blood pressure to get out of hand. Don't allow hypertension. The risk of a hemorrhagic conversion is very, very low.

- Okay. How about if the patient has a wedge shaped right frontal stroke from this? Yeah, go ahead.

- Yeah. I'm sorry. I didn't mean to interrupt. Yeah, if someone had a devastating stroke, so someone has a complete middle cerebral artery stroke and is hemiplegic, I would question the value of the nips lateral endarterectomy in that case. On the other hand, if someone still had significant brain to lose, still had reasonable function, the size of the stroke per se, or the wedge shape wouldn't keep me going ahead and doing endarterectomy early.

- Okay. So you don't really wait too much. You just go ahead and take care of the patient and avoid any further episodes. Do you think there's a role with an emergency endarterectomy in terms of stroking evolution or what we call Crescendo TIA in the face of severe carotid stenosis?

- I do. If you look at the data on patient stroke risks, following TIA, even on a standard TIA, it's highest in the first couple of weeks, I think the person who's really having Crescendo TIAs that risk is considerably higher. And I would go ahead and do a endarterectomy as an urgent procedure in someone who is having Crescendo TIAs.. For most TIA patients, I won't do it as an emergency or urgent procedure, but they will get loaded with aspirin and Plavix. And the next operative day, they're gonna go ahead with the surgery. I would say the same thing for the acute carotid occlusion that if someone's an elderly patient tolerating that, well, I wouldn't do anything about it, but the young patient with an acute carotid occlusion I would operate on because I there there's a good chance of reopening that vessel.

- Okay. And for tandem lesions, do you think opening the vessel proximally would ameliorate some of the symptoms that could be attributed to the distal lesion?

- Yeah, the approach I've used is if it looks like Berkeley and you really do need to be treated, I think that's a good indication for endovascular treatment. And I would refer that to Kevin Cochran here who would treat both the lesions in the vascular away. On the other hand, if someone has a moderate distal stenosis outside of operative exposure and a severe proximal internal carotid stenosis, I would simply treat the proximal stenosis with an endarterectomy and treat the distal stenosis medically.

- Thank you. And as you mentioned, you don't believe Plavix is associated with increased risk of bleeding. This is another controversial issue. As you can see, this patient has on the left image a significant left carotid stenosis and has a small proximal M1 or mid M1 aneurysm. How would you treat these patient? Let's say this patient had a five millimeter versus a seven millimeter intracranial aneurysm. Would you treat both or only the carotid or any other thoughts?

- Yeah, I would make the decision independently as to whether or not the aneurism and carotid needed to be treated. Yet the answer was the aneurism could be safely observed with the carotid needed to be treated. I wouldn't hesitate to go ahead and do an endarterectomy in that case. If both required treatment, I would go ahead and do the endarterectomy and get that taken care of and then address the aneurysm either endovascular or surgically, I'll go with is most appropriate.

- Okay, so in this patient, you would just do the endarterectomy because the aneurysm is less than five millimeters? Therefore you would just observe the hemorrhage.

- Right, for this particular patient, assuming that's a symptomatic carotid stenosis and an asymptomatic artery aneurysm, I will go ahead and do the endarterectomy and simply use survey elements for the aneurism.

- Thank you. Imaging, if you see ultrasound findings, I assume you go ahead and with MRI and CTA, you just don't treat people with ultrasound alone because you wanna pick up those rare patients with tandem stenosis. And when would you do an angiogram? And do you believe that MRA overestimates the stenosis and angiogram underestimate the stenosis?

- Yeah, I think that ultrasound is a good screening chest. It's good to follow these patients, but as a sole study to make an operative decision it leaves a lot to be desired. I very rarely do asymptomatic carotid stenosis anymore. I think the medical management of that problem is so good now that it's hard to make a case that you improved the outcome for most people with surgery. I think, you know, if the ACAS and a European studies were repeated with the kind of medical management of delayed symptomatic stenosis we have now, I'd be very surprised if they showed a benefit. Having said that the patient, I will do an asymptomatic stenosis if it's the young patient where the patient who showed a very rapid progression of stenosis. Either MRA or CTA are very good studies, Sundt, almost all symptomatic patients now most commonly we'll get an MRI of the brain looking for ischemic injury. And at the same time do MRA of the cervical and intracranial circulation. I don't think it significantly overestimates the degree of stenosis, and particularly in symptomatic patients. So I don't worry about that. The only time we do an angiogram now is if we had asymptomatic patient who shows occlusion on either ultrasound or MRA. And I do the angiogram in that case for two reasons, sometimes we use CT angiogram actually, and occasionally you'll see someone who has a string sign where you can still get that vessel open. That just the flow was so slow, that it didn't show up on an MRI. Or, you know, we'll see someone who truly does have an occluded internal carotid, but has big backfill down below the skull base. And in that case, I have a very good chance of reopening that vessel, and we'd go ahead and do that. Now within the last couple of years, CT angiography has gotten so good that that's largely replaced angiography even in those circumstances. So over the last year or two years, I mean, we've just done almost no angiograms for carotid disease.

- Thank you, Bob. So this is a classic, you know, CTA findings and these coronal image on the left side, as you can see. Can you see my Chrome everyone now? I'll go ahead and reactivate my arrow so people can see it. So as you can see on the left image, there's a right sided carotid stenosis right there. That's really his full limiting. And as you can see on this angiogram there is evidence of severe stenosis. And these are again the classic presentations for carotid stenosis on imaging. Let's go ahead and talk about some of the nuances I have personally used. Bob, let's shoots sort of comment and we use the illustration sort of augment for our viewers, how to do this. Again, really bending, reflexing the leg and sort of bringing the leg down sometimes really helps in terms of making sure the patient doesn't move on the bed. I do use it the way for which is different than you do. Again, general endotracheal anesthesia with EEG monitoring. I think there is advantages with an awake case the monitoring is more robust, the patients most likely go home earlier because they don't have to undergo general anesthesia. However, you know, I do let my residents do a portion of the operation, and that technically can take longer, and having the patient awake can be a limiting factor in terms of inclusion the residents in the surgical procedures. So I have come to, as a really a main teaching tool, I use the general anesthesia with EEG and also using heparin 5,000 just before starting the endarterectomy. Just like you mentioned. Ears incision, I think cosmetically the horizontal incision is better. I guess it's a matter of training where you go and how you get used to things. We have used the sort of slightly curves, S-shaped incision and where the mandible, the angle of mandible is, that's where the incision turns posteriorly in terms of making sure you don't injure the marginal mandibular branch. And again, this is just the superior margin of the clavicle. This is an illustration, Bob, just talking about the major points in terms of the marginal mandibular branch. It's located right along the angle of the mandible. And people often, you know, wonder why that occasional patient has the crooked smile and the lower lip is somewhat paretic. And that's because when they retract here too aggressively, and that's probably more common with virtual vertical incisions, they really cause a temporary dysfunction or neuropraxia on this nerve, and usually the recovers within six weeks. And you just have to assure the patient, but if you really wanna know where the source of that crooked smile is, which I didn't know for a while, until I looked at the illustrations is right at the angle of the mandible line. And that's because of aggressive retraction in that region, which should be avoided. Do you have any thoughts about that complication, Bob?

- Firstly, I would agree completely with what you've said it's usually the traction related, almost always gets better in a few weeks. I think it is a little less common with the transverse incision. Occasionally, we'll see a cranium marginal mandibular nerve palsy related to injection wide cane up along the sternocleidomastoid muscle. And that usually goes away in a few hours. It is important to recognize because I've seen recovery pneumonosis misinterpreted because the marginal mandibular nerve depresses the lower lip. You ask someone to smile and that lip doesn't come down. The other side of the lip does, and I've seen nurses misinterpret that as a contralateral facial palsy. I don't think it has a lot of long-term significance, but it is important to recognize in the immediate post-op period.

- Thank you. So again, using the covene incision along the enter edge of the sternocleidomastoid, as you can see there, obviously you can cut through the platysma and then you really feel the carotid and try to stay more lateral than you think, because it's a lot easier to expose the jagular and then find yourself to lateral along the medial edge of the sternocleidomastoid muscle. You must or rather move to medial, injure the recurrent laryngeal nerve or some of the neck muscles and leave the patient with significant deficits, including hoarseness and potentially swallowing difficulty. And again, we use the metzenbaum scissors, as you very well mentioned. And here is really an image with my finger trying to stay on the more medial edge of the sternocleidomastoid and look for that pulse. It can be really easy, especially on a heavy set individuals and large necks to get lost and find yourself in no man's land. So I think it's always important to stay as lateral, close to the sternocleidomastoid, if you don't feel comfortable and you can always move lateral, as long as you don't injure jugular. So here is really ligating the common facial vein, as have been long mentioned, and really ansa cervicalis may run just medial to that. And obviously, it's not a very important nerve if you injure it and you probably have to cut it more superiorly. If you have to mobilize the hypoglossal nerve more medially and superiorly. We ligate it obviously with two strove sutures 2-0s. And then opening the carotid sheath and suturing sheath laterally really lifts up and elevates the whole arterial complex and makes your job very easy. So if there is any way, and there's evidence of a thick sheath that you can preserve and sort of sharply cut along its middle section inavertically preserving the edges would really help you to, you know, elevate the whole complex and make your job easier in the next stages. And again, there's different ways we use vesseloops in our vessels and also use a clamp just behind the vesseloop in internal. We use the vesseloops because we also use them as a traction tool in order to lift up the complex. And we find that very helpful. We use a full loaded clamp. I think you mentioned Rummel that works very well. And again, vesseloops and a small aneurysm clip on the superior thyroid artery. We also use good amount of traction on the external because it doesn't have major consequences and also really elevate the external carotid artery, and really put some traction to move all the complex superiorly. So here is an intraoperative image box showing how the detraction sometimes on external helps for us and really move the internal closer to the surface of the operation and into the surgical field. Again, to this section, I think the anatomy is very pretty. I always love doing a carotid endarterectomy. You can see the common facial vein, you can see the hypoglossal nerve, you can see the hypo... Sorry, the ansa cervicalis eventually joins the hypoglossal. And usually you may transect it here to move the hypoglossal more laterally. So as you can mobilize the nerve more medially, and this is really a more pronounced ansa cervicalis. Any thoughts, Bob.

- Yeah, hey, this is a beautiful anatomy, beautiful dissection. And now this looks like a fairly low bifurcation. So you already have a good deal of internal carotid with that bifurcation work higher than you would need to go up, you know, lateral to the hypoglossal nerve. This is just a beautiful demonstration of the common facial vein going . But I agree with everything you said about.

- Here is another illustration of sort of starting your atriotomy using a knife so I get the level of this, so part of the common artery and moving really using a pot scissors. And again, if the stenosis is very narrow, this really can push you toward the bifurcation, just like you very well mentioned. And the surgeon has to avoid that urge and continue moving along the mid line of the internal carotid artery to assure that the atriotomy is not jagged which would make the closure very difficult. Often they had plaque can be very calcified, and that would really be often difficult with just the scissor and you may even use a knife to cut through the calcified portion of the plaque arch. Here's sort of the next step as you were very well illustrated, as really dissecting and find the plane between the plaque and arterial wall and moving on both sides and trying to dissect off the plaque without injuring the wall of the vessel. Obviously, you don't wanna be too aggressive and cause injury in the wall, but just clean enough. And if you leave small plaques, you can always come back and clean them later. Any thoughts in this area?

- No. I agree with everything you said. One neat trick. If you have a really heavily calcified plaque, that's hard to go through is to actually dissect, make your incision above the plaque. Robert Oshman used to do that because he and the Pusher wanted to get the plaques for analysis. So he would do an extra plaque dissection, not actually cut into the lumen. But I found occasionally a really heavily calcified plaque where it's hard to get your pot scissors through it, pull a portion, you can go outside the plaque and go distal to the plaque that way as well.

- Okay, so stay out of the plaque on the very calcified far and just come back and cut through it with a knife or something that would go through the calcified portion. And here again, using micro scissors, I think this is the most important part of the operation, knowing where to cut that plaque distally and using micro scissors or wherever the plaque is giving you, whatever it gives you, where you can disconnect it, often helps very well. You can use the micro scissors and cut where you are, and then always come back and clean it out further. And that's what we have done, but it's really critical that you'll have a very clean edge of where the plaque is cut. And if you have, you know, really on smooth edge, that can be a very possible source of emboli after surgery and potentially thrombosis. And here's the next stage, really trying to dissect the edge of the plaque that goes into the external carotid artery. Continue to dissect the plaque and you used pot scissor to create an area where you have to cut. Again, this goes all the way to the heart and you have to make a decision where to stop. Any nuances at this stage of the operation now? Bob, please.

- I think it's almost never necessary to transect the plaque distally. Almost always you can get it to feather out. If you move far enough this way along the vessel. Occasionally, you can't and you do have to transect it, make sure there's no shaft left. As you said, proximally, you always have to transect it. You might get to the end of it. And you know, I don't think that the shaft matters on the proximal one because the flow always proximally to internal carotid, and you're not going to... That's not gonna set you up for the section. And some of the other things that a distal shelf could cross.

- Thank you. And here again is taking a time and being patient when you dissect the plaque, as it goes into the external carotid artery. And obviously, you don't wanna leave a stump of the plaque here, which could also create a thrombotic surface. You may have to loosen up the external carotid vesseloop in order to get a nicer dissection around that plaque. And then that plaque obviously is pulled out of the external using, you know, Shelly clamps or something else. So again, they have all stumped stays very much deep into the external. And really taking time irrigating with Heparin. We can see all my arrow. Okay, Michael. We can irrigate with it Heparin pretty well at this point. Find those little plaques and make sure they are very much removed. We do do this operation under microscope that obvious always exaggerates these plaques a little bit and does take extra time. And I will show you the video. The first suture that we put, we go out, in, and then in out, because you really wanna make sure the cutting-edge of the plaque is very much tack down. You don't wanna go in one cut, that you really wanna stay a little bit above the arteriotomy in order to prevent any additional stenosis with your sutures. We do go on both sides from distal to proximal and then proximal to distal. And also we tack down the edges of the plaque inferiorly by going out, in, in, out, as you'll see in a video in a second. Any tenants of technique here, Bob?

- No, I agree with everything you said. And this, you know, the plaque removal, making sure that you have a nice clean vessel, and meticulous closure is really the heart to this operation. And everything else ends up being mostly personal preference.

- Thank you. And the here again in backflow that is so critical. That you loosen first vesseloop and you let things, you know, back flow and make sure you do have a backflow. If you don't have a backflow, you need to reopen your suture line. And if you don't see any thrombus, you may send a full gritty, a catheter up and try to remove some of the clots. That is an important part of the operation. And the backflow after it is done, you can continue sort of finishing your last suture, tying it up. And we opened a flow first in external and then in common. And that's really the blood from the common going into the external and take all the air and thrombi with it, and after a minute of to open the internal carotid artery. If you don't have a good flow back from the internal and you open your suture line and you clean it out and you don't see anything, Bob, what would you do next?

- I would do what you have just said, that I don't see any technical problem. I would put a probiotic cathedrop, and usually is a two or three would pass it as far as you can, until you feel resistance then blow up the balloon and pull it back. If it is a thrombus, what you'd expect to see is, you know, this backward and once a thrombus is there and then you can go ahead and really close it. If you can't establish flow back and you are not sure if there is a distal thrombus, if the patient has remained neurologically well with an awake, an anesthetic well, the EEG looks fine with the general anesthetic, I think it's better to do a cranial ligation in the internal carotid at that point, and a common carotid, external angioplasty. So you have good flow without a stump rather than take the risk of blowing a thrombus into the intercranial circulation.

- Thank you. And here is a picture of the plaque. Let's go ahead and review a couple of videos, just again, alternative methods for endarterectomy, and get your opinion. And this is a 55-year-old female with a left sided carotid stenosis. So here's the video of a left sided carotid endarterectomy, Bob. And as you can see, the incision has been completed. Finding the common facial vein, very superficially. Passing a couple of ligature. You can pass both sutures at the same time. Please go ahead and interrupt me as you see fit, Bob. Here is I think opening again, some of his soft tissues over the carotid. Here was a very robust carotid sheath, and we're putting it or retracting it using the V-shoots and really elevates the whole complex and leaves you with a dissection plane that you can start proximally. And as long as you open that carotid sheath early on, or put a suture in it, as you can see here, you can really continuing that plane and makes the dissection so easy. Here is you can see the hypoglossal nerve, and the carotid sheath if it's left intact, you can just lift up the carotid sheath and leave the hypoglossal nerve on the other side of the sheath and really using this sheath as a way to protect the nerve. Sometimes there could be additional tough membranes around the internal that may be opened in order to really get a clear look at the outside surface of the vessels. As you can see, this is performed under operating microscope. We don't do the exposure under the microscope. This is more for the viewers can see this recording. We generally try to do the closure and the cleaning of the vessel under the microscope. It does make the procedure slightly longer, but it typically saves my neck from looking down and having a slight neck pain afterwards. And it gives you a better way to visualize, as sometimes it could be small veins right here next to the hypoglossal nerve, that as you mentioned in your talk, they have to be coagulated. And ansa which may join the hypoglossal nerve may be here that can be cut in order to mobilize the nerve anteriorly. And here is the vein, you can see. It is often very constant and very sort of problematic because if you cut it, it causes a lot of bleeding and you have the hypoglossal nerve around and you don't wanna coagulate the nerve. So it's best to sort of take it early on and coagulate it and not to worry about it later rather than running into it and cause bleeding where you're trying to protect the nerve. Again, that if the bifurcation is more superior than usual, you may have to extend your incision or a dissection more superiorly. As you can see, the hypoglossal nerve is right there and he's being mobilized by the carotid sheath out of the surgical field. Again, soft tissue dissection has to be done patiently here, just like you mentioned, Bob, in terms of protecting the hypoglossal nerve and causing its inadvention injury. And here is the final product where the nerve again, is on the other side of the carotid sheath. Any nuances at this step, Bob?

- No, I agree with everything you said. I think that that distal exposure is critical. And the only way to get it is to come up lateral to the hypoglossal. You always find vessels there, embedded or coagulated and divide them early. So I agree with everything you said.

- And sometimes there can be some bleeding around the bulb and you may use bipolar. It is really important to get as soon confessional dissection along the common. Be careful underneath as you can see the sheath has been very well protected here. Be careful of the vegas at the bottom, but that should not intimidate you in terms of getting a good circumferential dissection around the vessel to get a good control in case you run into trouble. We do use a gentle, as you can see clamps directly on the internal. That also helps because we put a vessel in front of it and then pull the clamp more superiorly. And that gives us a few extra millimeters in terms of exposure of the distal internal. Again, here is starting to arteriotomy, staying on the common carotid, being generous with your arteriotomy and not necessarily get close to the bifurcation to save time. Using pot scissors, if the stenosis are narrow. It can be really difficult to go through this stenosis and the surgeon may have to stay on the outside the plaque. The nuance, Bob, you just mentioned. And then go to all this internal and then come back and cut through the plaque. Finding the plane between the plaque and the wall is also important. You don't wanna start at the wrong spot. Usually, it's relatively easy to find, and it's just important to sort of follow what it gives you rather than make a plane of your own. That's usually means you're on the wrong plane. And you are putting the inner surface of the vessel at risk. Any nuances in terms of the removal of the plaque?

- Yeah, again, I think try and get it to tether up distally. You know, sharp transection proximally. And I keep pointing that making up a plane or allowing the plaque to show you the right plane of the section is important because if you can really get into the vessel wall by the time you get to the back of the plaque, you may not have any vessels to work with. And I think this again, the key to this operation is that you wanna get a meticulous plaque removal. So you have a nice smooth vessel and then close it meticulously. And regardless of what other things you do, you're gonna have good outcomes.

- And I think, a moment ago, you saw cutting the plaque along the common edge, and here is really dissecting generously and pulling the plaque out of the external, not to leave a stump and the thrum or genic surface And using Heparin irrigation, and really cleaning that vessel real well. Don't wanna leave any little flaps that would create emboli and leave you with a really a neurological deficit after surgery. It's just not acceptable in this era to do carotid endarterectomy and have patients have significant deficits after surgery. It's an operation that can be performed with relatively very low risk, but it requires patience and really cleaning the vessel wall. The microscope may help here, as you can see, because you're really focusing on every little detail Again, if there is an edge of the plaque at level of the common carotid artery, you wanna really make it look clean and there's no edges where it would form a chance for emboli later. This patient has a very generous diameter of his carotid after the procedure is completed. And I think the closure will be relatively easy and the patient would not require any patch. And here is really the distal part of the plaque. And spending that time, making sure these edges are clean and there's no flaps especially along the posterior wall that require tucking stitches. And again, usually the plaque will let you know where you need to cut it. It may require that you have to extend your arteriotomy more distally to able to find where it needs to be cut or what the natural plane is or the edges. And if you have to do that, you have to be ready to extend your arteriotomy. And if you have an inadequate exposure, that's usually where you run into trouble because you no longer can extend your arteriotomy. Here is just moving with the out, in, in out technique, keeping the flaps with you. Is that the way you start your suture, Bob? Or do you use a different technique?

- No. Exactly like that.

- And again, going for the first stitch or two, you may wanna go out in and out to be able to see the flap and don't drop your needle holder in your surgical peel, if you can avoid it. Again, this is probably too much magnification, which is not good either in terms of making sure you are not leaving any flaps and making sure everything is very clean. And really here on, you wanna stay on the edge, not too close to the edge in order to have a very smooth surface after the closure is done. But as you can see in this patient, the internal and common were very patchoulis. So we had good amount of sort of arterial wall to work with. So as you can see, there is more edge is being included in the suture than we usually do, just because of the extra wall that we had the luxury of after the endarterectomy was completed. And here is again, starting distally using the same technique. And I think that's one advantage of going from both sides, is that you can tuck your stitches maybe a little bit better going out in, in and out, making sure that the flaps are tucked efficiently, and then starting from the bottom up and meeting in the middle and then doing your back bleed along the internal. You can see the edges are a relatively jugged and on smooth here, and that's why we used extra wall, which was available just to make it clean. Again, I think that's more than usual in terms of including in the suture. Anything else you would have done differently here, Bob?

- No, I usually don't transect the distal plaque. I make a fetish of trying to get it far enough up so that it feathers out, but I think this looks very nice and we'll have a nice patchoulis vessel, cleaned up. So I'm sure this person will do fine. So I think this looks fine.

- And as you can see, we just backup blood internal and we've got a nice flow to clear some of the air, and finishing your last suture. And then really proceeding with first, opening the external then common, and last internal. It's the exact reverse, how you start the arteriotomy where you clamp the internal first, and then common and external. You may have some bleeding, as you can see most often it happens on the internal side of things. And you may have to put an extra suture if our arteriotomy is not perfectly done and that usually takes care of it. I think it's best to be patient and fix it with a suture. Don't cause osteomiosis rather than try to get out of the case quickly and put material that are hemostatic, but later could cause a hematoma in the neck and cause the patient to return to the operating room. And here is the final product, and obviously a satisfying operation. We're gonna go ahead and show one last video, Bob, and I appreciate your patience here. 74-year-old male with right-sided carotid stenosis. And in this patient we felt that the carotid was not as generous, and especially the internal. And we went in her head and patched the vessel. Again, this is a right-sided carotid. And you can see in this situation, we just placed the aneurysm clip because the internal was not as generous as before. The endarterectomy is started. I have found that if you have back bleeding at this juncture and all your clamps on the large vessels are okay, it is most likely there is ascending pharyngeal that you missed because it was embedded in soft tissues. So if you check all your vessels and everything looks pretty good and you still are getting back bleeding, obviously you wanna reassess the situation and see if there is. And here is again, moving along the distal parts of the arteriotomy in the internal. And as you said, usually there is a good plane. And as you can see, maybe sometimes starting it with a micro scissors may help, and then afterwards cleaning it out. But trying to create a edge of your own can be problematic. Here you can see, I did not do a good job in cleaning it up, but the backflow is pretty good. And once in a while, I always check the backflow, make sure we didn't cause any trouble distally and then come back and really clean it up very well. As you can see here. This is after the distal part is cleaned out. The proximal part will be cleaned out a little bit more and trying to remove the plaque in the external. This is a technique of the patch graft that we have used. And again, going from the patch to the inside the vessel, to outside. And the first few sutures, you have to go again from out, into the graft, come out completely and then go into the vessel wall. And you tuck down those flaps at the end of your, what you call plaque removal. I think being patient at that juncture is important to make sure there's no a flap that can cause emboli again. Any nuances, Bob, in terms of suturing grafting?

- No. I did the same thing. You know, when you go outside in at the top, and I just use a double arm suture and then run one down, one side and one down the other, but basically it's just as you're demonstrating. And you know, some people don't, lot of carotid. Chris Loftis for instance, will swear by patch grafting everyone. And as you mentioned, Sundt, really like patch graft in vessels as well. You'll get other people, SpecFlow for instance, who says he never patch graft. I do it rarely, but I think there are occasions with a small vessel when it's very helpful. I've stopped doing redo carotids 'cause I think they're better done endovascularly, but one indication for a patch graft was a patient who'd had a previous endarterectomy.

- Thank you. And we're gonna finish up with just a final pearls and pitfalls on this procedure. Obviously, there are complications, a wound hematoma, hypertension, hypotension. I think the hypertension has to be very carefully managed because it can cause hyperperfusion syndrome because of the significant carotid stenosis. The autoregulation in the cerebral vessels may be compromised. And therefore, when you have a re institution of high flow after the endarterectomy is completed, this loss of autoregulation may cause hyperperfusion syndrome or potentially intracerebral hematomas, seizures. And again, I think hypotension has a risk of graft occlusion, although that risk is small. And if the hypertension is significant, the patient has to be evaluated for evidence of cardiac schema. If there is evidence of wounded hematoma, and in PACU, and there's airway compromise, you've got to open the wound by the bedside. There may not be enough time to go back to the operating room, and the anesthesiologist may not be able to intubate the patient because of the significant tracheal deviation by the hematoma. High potential, again, treated by fluids, rule out hematoma. Very rarely we use pressors. And you have to manage the cranial nerve palsies very well after surgery. And if there isn't evidence of acute hemiplegia in PACU, most surgeons take the patient immediately to the OR because time is of the essence and you don't necessarily wait to do a study to see what's going on. If you go into the OR, and you don't get a good back flow after you open your arteriotomy... I'm sorry, your anastomosis edges, you may have to send a Fogarty catheter in to the internal carotid arteries. In other features, I know this comes up pretty much on the boards a lot that people should know in terms of managing complications of endarterectomy, Bob?

- The only one I would disagree with is the acute hemiplegia. We actually looked at our series and found that it's a distinct minority that have a problem at the operative site. And so by taking someone back to the operating room, reopening that vessel and then finding there's nothing to do there, they're actually delayed treatment. So what we've done is take the person originally to the CT scanner, scan the head, make sure it's not a hemorrhage. Then do a CT angiogram, which can be done very quickly. And often what you'll see is distal thrombus, distal embolus that widely patent or the way your surgery was done, and that patient can then go directly to angiography to see if there's something that can be done for that. Other than that, I would agree completely with the management, but we have stopped taking people back originally to the operating room today. We had a deficit in the recovery room.

- Bob, I wanna thank you for your expert discussion. I think this was extremely helpful, and I'm sure our viewers appreciate similarly. So I wanna thank you again for your time.

- And thank you, and the AANS.

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