NAME: Jandul, Fatima Nurfaida J. Clinical Instructor: Prof.

Maricor Gaan, RN
YR & SEC: BSN 4B Clinical Area: ZCMC- Ward 4
Rotation Date: 12|Sept. 13-15, 2010

ENDARTERECTOMY

 Endarterectomy is a surgical procedure to remove the atheromatous plaque material, or blockage, in the lining of an
artery constricted by the buildup of soft/hardening deposits. It is carried out by separating the plaque from the arterial
wall.
 The procedure is widely used on the carotid artery of the neck as a way to reduce the risk of stroke, particularly when
the carotid artery is narrowed by more than 70%. A carotid endarterectomy may itself cause a stroke at the time of
operation.

 Endarterectomy is also used as a supplement to a vein bypass graft to open up distal segments.

 Pulmonary hypertension caused by chronic thromboembolic disease (CTEPH) may be amenable to endarterectomy of
the pulmonary artery. This is a highly specialized procedure.

 The term atherectomy is used to describe reconstruction through a catheter.

 Carotid endarterectomy (CEA) is a surgical procedure used to prevent stroke, by correcting stenosis (narrowing) in the
common carotid artery. Endarterectomy is the removal of material on the inside (end-) of an artery.

Procedure

The internal, common and external carotid arteries are clamped, the lumen of the internal carotid artery is opened, and the
atheromatous plaque substance removed. The artery is closed, hemostasis achieved, and the overlying layers closed. Many
surgeons lay a temporary shunt to ensure blood supply to the brain during the procedure. The procedure may be
performed under general or local anaesthesia. The latter allows for direct monitoring of neurological status by intra-
operative verbal contact and testing of grip strength. With general anaesthesia indirect methods of assessing cerebral
perfusion must be used, such as electroencephalography (EEG), transcranial doppler analysis and carotid artery stump
pressure monitoring. At present there is no good evidence to show any major difference in outcome between local and
general anaesthesia.

Minimally-invasive procedures have been developed, by threading catheters through the femoral artery, up through the
aorta, then inflating a balloon to dilate the carotid artery, with a wire-mesh stent and a device to protect the brain from
embolization of plaque material. The FDA has approved 5 carotid stent systems as safe and effective in patients at
increased risk of complications for neck surgery. In the SAPPHIRE study, Yadav concluded that this procedure, known as
carotid stenting, was non-inferior to carotid endarterectomy in total adverse events, and lowered event rates for major
stroke, cranial nerve palsy, and myocardial infarction, in patients at high risk for surgery.[11] It is the consensus of experts in
the field that carotid artery stenting should be considered an option for patients who require carotid artery
revascularization to prevent stroke and who are at increased risk of having surgical complications.

Possible Complications of Endarterectomy:

Incisional Hematoma, Postoperative Hypotension, Intracerebral hemorrhage.

Hypertension, Hyperperfusion syndrome, Risk for further stroke

What are the actual benefits from carotid endarterectomy?

The pooled data from both trials provides the firmest evidence of benefit. Carotid endarterectomy was only helpful in patients with
greater than 50% narrowing of the internal carotid artery. The more severe the narrowing the greater the benefit in reducing further
strokes. There is no benefit in having an operation once the artery is blocked.

In patients with 50-69% narrowing the risks of stroke or death were reduced by 7-9% at 5 years after surgery. In patients with more
severe narrowing greater than 70% the risks of stroke or death were reduced by 14-19% at 5 years after surgery. In certain groups of
patients with very narrowed arteries the benefits of surgery can be even greater.

It is important to realise that these reductions in risk for a patient are very great when compared with other medical measures to prevent
stroke or death. For instance the use of drugs to lower the cholesterol level only reduces the risk of death by 1-2%. The benefits for
carotid endarterectomy are many times greater than taking tablets.

Be careful when reading claims regarding reductions in risk particularly for medications used to lower blood pressure and cholesterol. For
instance a reduction in the risk of dying from 2% (2 in 100) to 1% (1 in 100) is only an absolute benefit of 1%. That is only 1 person in
every 100 will be helped. Ninety nine patients in every 100 will take tablets with no benefit. Unfortunately, to make this 1% absolute
benefit appear greater, it is sometimes expressed as a 50% relative risk reduction because the risk has been halved from 2% to 1%. There
is still true benefit in these circumstances, but it is much less than it first appears. The old saying that there are lies, damn lies and
statistics is nearly true.

NURSING CARE FOR PATIENTS UNDERGOING CAROTID ARTERY ENDARTERECTOMY

Nursing
diagnosis Interventions ** using a surgical drain if needed.

Risk of injury * Confirms identity and verifies * Provides postoperative care to

related to consent before surgical procedure. include
impending
surgical * Verifies correct surgical site ** elevating head of bed to
procedure with patient, surgical consent, OR decrease venous pressure,
schedule, surgeon, documentation
on patient chart, and radiology ** collaborating in maintenance
results. and corrective therapy of
bleeding problems (eg, monitoring
* Verifies NPO status. blood thinning therapy,
administering reversal agents),
* Verifies allergies.
** monitoring for tracheal deviation
* Considers mobility limitations should bleeding or hematoma
pertinent to this population when occur, and
positioning to include residual
stroke deficits, cervical arthritis, ** monitoring for neurological
and limited joint mobility. status (eg, midline tongue
protrusion, symmetrical facies)
* Applies safety devices when
positioning patient for surgical site Risk of stroke * Performs preoperative evaluation
exposure to include placing a pillow related to to include baseline neurological
under the knees to relieve low surgical function.
back strain, elevating the head of intervention
the bed, and providing a head and impaired * Provides preoperative treatments
donut and shoulder roll for cranial nerve to include controlling blood
hyper-extension of the neck. function pressure with antihypertensive
medications.
* Evaluates for signs and symptoms
of physical injury. * Provides intraoperative care to
include
Risk for * Identifies baseline cardiac status
decreased and reviews diagnostic evaluations ** using care in handling vessels
cardiac output (eg, preoperative stress test, to avoid embolization and
related to electrocardiogram [EKG], laboratory trauma to cranial nerves and
cardiovascular test results, others as
function, indicated). ** evaluating for adequate blood
anesthesia, and flow in carotid vessels.
surgical * Identifies and reports presence of
intervention implantable cardiac devices (eg, * Provides postoperative care to
pacemaker, automatic implantable include
cardiodefibrilator).
** treating nausea, vomiting, and
* Uses monitoring equipment to restlessness appropriately to
assess cardiac status (eg, EKG, avoid hypertension;
arterial line, pulmonary artery
catheter) as indicated. ** evaluating adequate carotid
blood flow (eg, with doppler);
* Evaluates postoperative cardiac
function. ** elevating head of bed to
decrease venous pressure; and
Risk of impaired * Performs preoperative evaluation
airway related to to include baseline bleeding ** monitoring for neurological
postoperative profile. status (eg, midline tongue
bleeding and protrusion, symmetrical facies).
impaired cranial * Provides preoperative treatments
nerve function to include withholding aspirin ROLES OF THE RN FIRST ASSISTANT
and aspirin-containing products.
Preoperative
* Provides intraoperative care to * Performing preoperative patient assessment
include * Providing patient, family member, and staff member
teaching
** minimizing traction and trauma * Scheduling procedures
to cranial nerves, Intraoperative
* Assisting with patient positioning
** ensuring adequate hemostasis * Prepping and draping
before wound closure, and * Exposing the surgical site
* Retracting and providing hemostasis
* Using surgical instrumentation
* Handling tissue to include dissecting, suturing, tying,
stapling, and placing drains
Postoperative
* Performing postoperative patient assessments
* Evaluating diagnostic and laboratory studies
* Interacting with health care team members in the
patient's pain management

References:
http://findarticles.com/p/articles/mi_m0FSL/is_2_75/ai_83141045/pg_10/?tag=content;col1
&& http://en.wikipedia.org/wiki/Carotid_endarterectomy