Complications of CEA

Cerebral Infarction

Cerebral infarction is the most dreaded complication of CEA. Ischemic symptoms are seen in up to 5% of cases and can lead to major stroke in 1-3% of cases. Intraoperative monitoring and shunting can potentially minimize cerebral ischemia, due to hemodynamic factors. Thromboembolism with associated complete occlusion of the carotid artery is the most likely etiology of cerebral infarction following CEA. Prompt surgical exploration may be indicated. Diagnostic studies such as a CT scan to rule out an intracerebral hemorrhage and TCD to document hypoperfusion or emboli in the MCA territory are adjuncts when evaluating patients with new-onset neurological deficits in the post-operative period [34].

Cranial Nerve Injuries

Cranial nerve injury may be a complication of CEA. These injuries can be associated with significant morbidity. Injury is usually related to surgical technique and can be avoided. Use of magnifying instruments and careful attention to hemostasis with bipolar electrocautery, as well as gentle handling of the nerves that need to be mobilized, minimize this complication.

Injury to the hypoglossal nerve (CN XII) usually presents with unilateral tongue weakness, dysarthria and swallowing difficulties. Spinal accessory nerve injury needs to be considered in the patient who complains of ipsilat-eral shoulder drooping. Cutaneous anesthesia over the ear lobe and angle of the jaw may be due to injury to the greater auricular nerve and cutaneous branches. The vagus nerve can be injured in up to 6% of cases and presents with dysphagia or hoarseness caused by vocal cord dysfunction. Injury to the vagus by retraction on either the superior or recurrent laryngeal nerves can be prevented by identifying the vagus in the carotid sheath and by careful placement of the retractor blades. Most patients who develop dysphagia or hoarseness after CEA can be managed expectantly, since most recover spontaneously. It is important in the patient with bilateral carotid stenosis that, upon completion of one procedure, examination by an otolaryngologist, looking for occult vocal cord dysfunction, is performed prior to proceeding with the second procedure. Bilateral injury to the vocal cords can result in respiratory compromise and require a tracheostomy.

A transient or permanent injury to the mandibular branch of the facial nerve can produce a cosmetically disfiguring result. Curving the skin incision posteriorly towards the mastoid process so that it is 1-2 cm below the angle of the mandible can usually prevent this injury type. Injuries to the superficial cervical plexus and the greater auricular nerve produce a noticeable paresthesia as a result of transection but it is usually transient, since the nerve regenerates.

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The term vaginitis is one that is applied to any inflammation or infection of the vagina, and there are many different conditions that are categorized together under this ‘broad’ heading, including bacterial vaginosis, trichomoniasis and non-infectious vaginitis.

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