Identifying the High-risk Patient with Clinically Relevant Embolisation After Carotid Endarterectomy

ObjectivesSustained embolisation after carotid endarterectomy (CEA) predicts an increased risk of stroke due to post-operative carotid thrombosis (POCT). Progression towards stroke can be prevented by transcranial Doppler (TCD) directed intravenous Dextran therapy. However, TCD monitoring is extremely labour intensive. The aim of this study was to see whether a small cohort of high-risk patients could be identified following a 30-min period of monitoring in the Recovery Area of the operating theatre so as to reduce the overall burden of monitoring for the majority of patients.MethodsRetrospective audit of prospectively acquired data in 821 patients with an accessible temporal window who had undergone 3 h of TCD monitoring after CEA. Patients with >25 emboli in any 10 min period or large emboli distorting the waveform received Dextran.ResultsGroup 1: 694 patients (85%) with ≤10 emboli detected within the first 30 min in the Recovery Area of the operating theatre. Recovery: None required Dextran, none suffered a proven ischaemic stroke and none were re-explored. Group 2: 127 patients (15%) with 11+ emboli detected. Overall, 26 (20%) required Dextran (54% had the dose increased to control excessive embolisation), none suffered a stroke due to POCT, but 2 suffered embolic strokes despite Dextran. Both, however, had mitigating reasons why optimal Dextran doses could not be administered.ConclusionsTCD directed Dextran has abolished stroke due to POCT. A high-risk cohort of patients requiring Dextran can be identified by measuring the magnitude of embolisation in the first 30 min in Theatre Recovery. The vast majority of patients (85%) require no further monitoring.