Microsurgical Carotid Endarterectomy for Highly Calcified Plaques

Background: Cases of carotid stenosis with highly-calcified plaques are associated with less expansion and intraoperative hypotension during carotid artery stenting (CAS). Therefore, carotid endarterectomy is recommended for highly calcified lesions. However, there is a risk of adventitial injury in carotid endarterectomy for highly-calcified plaques. We report our experience with microsurgical endarterectomy for highly-calcified plaques and discuss the pathological considerations.Methods: To obtain complete resection of the plaque with a smooth distal edge, a bloodless surface, and minimal exposure of the media, the thickened intima is incised under high-magnification microscopy. We reported this novel technique as “interintimal dissection.” The plaques are usually resected in en bloc fashion. However, en bloc resection may lead to vessel injury, because the media is very thin in the highly calcified segment. Thus, we intentionally leave behind the highly-calcified segment at first and then perform piecemeal resection.Results: Between September 2009 and March 2017, 162 carotid endarterectomies (CEAs) were performed in 152 patients with carotid stenosis. Highly calcified plaques were observed in 46 lesions. Complete resection of plaques without tacking sutures was obtained in all procedures. No deaths occurred. Stroke was recorded in 1 case (2.2%). No restenosis was recorded during follow-up (range, 1-82 months; mean, 45 months).Conclusion: Microsurgical interintimal dissection with piecemeal resection for highly-calcified plaques can achieve a good surgical outcome, including absence of significant early restenosis and vessel injury.