Eversion Carotid Endarterectomy Technique


2.3.1 Introduction

Carotid endarterectomy (CEA) is well established as a stroke-preventing treatment. Since the 1960s, two different techniques have evolved, namely conventional and eversion carotid endarterectomy, which is a modified version of the original method.

1. Conventional endarterectomy is the most common option for carotid bifurcation endarterectomy. It involves a longitudinal arteriotomy extending to the internal carotid distal to the lesion, and arteriotomy closure, which is made either using a patch or with primary closure.

2. The second technique is eversion endarterectomy, which was initially reported by De Bakey and later described by Etheredge, while a modification of the technique was presented by Kasprzak and Raithel in 1989 [4].

Eversion endarterectomy involves the oblique transec-tion of the internal carotid artery (ICA) at its origin at the carotid bifurcation, endarterectomy by eversion of the ICA, endarterectomy of the carotid bifurcation and of the external carotid artery, and reimplantation of the ICA on the common carotid artery. The advantages of eversion endarterectomy, like those of earlier eversion techniques, are that:

• It avoids longitudinal arteriotomy of the ICA

• It avoids the need for patch angioplasty

• It offers good visualization of the distal endpoint's smooth luminal surface throughout the length of the vessel that is being operated on

• It provides very effective management for the correction of carotid elongations with kinking and carotid tortuosities.

Also, in subsequent studies this technique has been found to be associated with lower stroke and restenosis rates [2,

4, 5]. However, no long-term double-blind studies supporting the superiority of this method compared to the conventional procedure have yet been published.

As a result, despite numerous innovations and reports, no unique CEA technique has yet become generally accepted for all patients and clinical situations. Furthermore, the superiority of one CEA method over another remains highly controversial and, thus, the optimal CEA technique to reduce postoperative complications and prevent late restenosis remains unclear. Under those circumstances, the EVEREST trial was designed to assess the major perioperative and late complication rates and durability of eversion CEA [1].

• EVEREST is a randomized multicentre trial.

• A total of 1353 patients with carotid stenosis requiring surgical treatment were randomly assigned to receive standard (n = 675) or eversion (n = 678) CEA.

• The primary endpoints included carotid occlusion, major stroke, death and restenosis rate.

• The results of the EVEREST Trial suggest that eversion CEA is a safe and rapid procedure.

• Also, the major complication rates appear to be low.

• No significant differences in restenosis rates were observed between eversion and standard CEA at follow-up.

• Longer-term results are necessary to assess whether the eversion technique influences the durability of CEA.

• Still, it appears that eversion CEA has many advantages in selective cases.

2.3.2 Technique

• Under general anaesthesia the patient is placed on the operating table in the supine position with the head hyperextended and turned away from the operative side.

Right Carotid Endartectomy
Fig. 2.3.1 Carotid bifurcation. A right bulldog clamp is used to control the internal carotid artery

• The skin incision is made parallel to the anterior border of the sternocleidomastoid muscle.

• Exposure and clamping of the common carotid artery (CCA), external carotid artery (ECA) and ICA are made in the usual way.

• Systemic heparinization is used.

• A right-angled bulldog clamp should control the ICA well beyond the distal end of the atheromatous plaque (Fig. 2.3.1).

• The CCA is entered with a scalpel while with angu-lated Pott's scissors the arteriotomy is extended in the distal direction toward the fork of the carotid bifurcation (Fig. 2.3.2).

• The incision should be made precisely parallel to the axis of the ECA.

• A common pair of scissors is then used for complete transection of the ICA (Fig. 2.3.3).

• Transection permits complete mobilization of the artery and additional traction downward offers additional length of exposure.

• Endarterectomy is started at the stump of the ICA and the plane is developed between the outermost layers of the media and the adventitia (Fig. 2.3.4a).

• The atheroma is circumferentially separated and detached while the outer layer of the vessel is everted (Fig. 2.3.4b).

• Fine atraumatic vascular forceps are required for these manipulations.

Eversion Carotid Endarterectomy
Fig. 2.3.2 The arteriotomy is extended by Pott's scissors towards the fork of the bifurcation
Fig. 2.3.3 Complete transection of the internal carotid artery permits further mobilization

• The eversion is progressively continued distally and the atheroma is detached like a cast (Fig. 2.3.5).

• Gentle traction results in complete removal of the ath-eromatous core providing a thin fading and tapering endpoint.

2.3.2 Technique

Eversion EndarterectomyEversion Endarterectomy

Fig. 2.3.4a,b Eversion endarterectomy of the internal carotid artery. a The plane of cleavage is developed by a closed fine mosquito. b As the atheroma is circumferential^ detached the outer layer of the vessel is everted

EndarterectomyCarotid Artery Plaque Removal

Fig. 2.3.5a,b Eversion endarterectomy of the internal carotid artery. a Further eversion of the outer layer of the vessel. b Removal of the atheromatous plaque by gentle traction; a smooth distal endpoint is left

Terminaison CarotidienneVascular Anastomosis Technique

Fig. 2.3.7 Reimplantation of the internal carotid artery. The anastomosis is started at the fork of the bifurcation and the posterior wall is reconstructed first

Fig. 2.3.6 Endarterectomy of the external carotid artery. Complete detachment of the plaque is achieved by the jaws of a closed dissector

Fig. 2.3.7 Reimplantation of the internal carotid artery. The anastomosis is started at the fork of the bifurcation and the posterior wall is reconstructed first

Carotid Stent Surgery

Fig. 2.3.9 In cases with distal plaque detachment and intimal flaps intraoperative stent deployment may secure the distal endpoint

Fig. 2.3.8 Reconstruction of the anterior wall of the anastomosis. Dilators may be used to dilate the extracranial segment of the internal carotid artery

Fig. 2.3.9 In cases with distal plaque detachment and intimal flaps intraoperative stent deployment may secure the distal endpoint

• As the atheroma is removed, the luminal surface and the transition between the endarterectomized and nonendarterectomized segment of the ICA are assessed carefully.

• Copious quantities of heparinized saline are used to flood the field in order to remove intimal or medial debris.

• Flaps or loose "residuals" are gently removed only by circumferential traction since cephalic traction can cause inadvertent intimal dissection of the ICA endpoint.

• The next step is attempted endarterectomy of the ECA and CCA.

• Circumferential mobilization of the plaque is achieved by utilizing the closed jaws of a dissector (Fig. 2.3.6).

• After proximal division of the plaque the endarterec-tomy is carried out into the ECA orifice as distal as possible.

• The arterial wall of the ICA is drawn proximal and the reimplantation of the artery to its normal position is started (Fig. 2.3.7).

• The anastomosis begins at the bifurcation fork using a simple running 6-0 synthetic monofilament suture.

• The posterior wall is reconstructed first with tiny bites (Fig. 2.3.8).

• Prior to completion of the anterior wall of the anastomosis, all clamps are removed sequentially to allow back bleeding and to wash out any thrombogenic debris.

• At this stage of the procedure dilators of appropriate size, up to 4.5 mm in diameter, may be used to dilate the extracranial segment of the ICA.

• Angioscopy may be also used to verify the anatomic result. Angioscopy yields an excellent visualization of the whole endarterectomized luminal surface and the endpoint of the ICA.

• After completion of the anastomosis the blood flow is restored first to the ECA and then to the ICA.

• In cases with distal flaps or plaque detachment, intraoperative stent deployment may secure the distal endpoint (Fig. 2.3.9).

2.3.3 Advantages

• The advantage of this modified CEA technique over the open endarterectomy is that longitudinal arteriot-omy of the ICA is avoided and subsequently the suture line does not interfere with the lumen of the vessel.

• Furthermore, the use of a patch in patients with small arteries, such as women and children, is not necessary.

• This method is appropriate for the correction of coiling, kinking or tortuosity of the ICA in the presence of arteriosclerotic lesions.

• After completion of the endarterectomy an ICA segment of appropriate length is resected and the vessels reimplanted.

2.3.4 Disadvantages

• Among the disadvantages of the method is the limitation of an internal shunt placement when it is required.

• During the procedure of eversion endarterectomy of the ICA, only a CCA to ECA shunt can be easily used for cerebral protection.

• In some complex cases, when the transition endpoint of the ICA is not smooth and/or the plaque is extended distally, replacement of the ICA by a graft may be necessary [3].

• In such cases, interposition of synthetic or saphenous vein grafts may be used.

2.3.5 Conclusion

In conclusion, eversion endarterectomy is a feasible and safe alternative technique for the management of extra-cranial carotid arteriosclerosis.

The major advantages of this technique are optimum correction of an elongated ICA, a lower restenosis rate and the avoidance of patch material for arteriotomy closure.


1. Cao P, Giordano G, Rango P, Zannetti S, Chiesa R, Coppi G, Palombo D, Spartera C, Stancanelli V, Vecchiati E (1998) A randomized study on eversion versus standard carotid endarterectomy: Study design and preliminary results: The Everest Trial. J Vasc Surg 27:595-605

2. Cao P, Giordano G, De Rango P, Zannetti S, Chiesa R, Coppi G, Palombo D, Peinetti F, Spartera C, Stancanelli V, Vecchiati E (2000) Eversion versus conventional carotid endarterec-tomy: late results of a prospective multicenter randomized clinical trial. J Vasc Surg 31:19-30

3. Cormier JM, Cormier F, Laurian C, Gigou F, Fichelle JM, Bokobza B (1987) PTFE bypass for revascularization of the atherosclerotic internal carotid artery. Ann Vasc Surg 1:564-571

4. Kasprzak PM, Raithel D (1989) Eversion carotid endarterectomy. J Cardiovasc Surg 30:495

5. Raithel D, Kasprzak P (1993) The eversion endarterectomy: a new technique. In: Greenhalgh RM, Hollier LH (eds) Surgery for stroke. Saunders, London, pp 183-191

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