This case was filed in the aftermath of a left carotid endarterectomy, where the patient never fully recovered from collateral nerve damage that left him with a debilitatingly impacted quality of life. Prior to the procedure, the seventy year-old patient was in relatively good health and had managed a busy auto repair garage, though imaging before his operation had shown moderate narrowing in the carotid artery and additional, mild narrowing in his left subclavian artery. While in post-operative recovery, he began to show signs of neurological deficit, including an inability to move his right upper and lower extremities, and was promptly taken back to the operating room. Despite efforts to repair the nerve damage, he returned from the hospital unable to run his business as he had been assessed as high fall risk, aphasia, and having memory and cognitive deficiencies.
Question(s) For Expert Witness
- 1. In your experience, what are the indications for performing carotid endarterectomies?
- 2.Which studies do you utilize in the preoperative work-up, and what is your threshold for operating?
Expert Witness Response E-000056
I have performed almost two thousand carotid endarterectomies and I am well recognized as an expert in the field. The usual indication for carotid endarterectomy in the United States is an asymptomatic high-grade lesion greater than 70%. Symptomatic lesions greater than 50% also require therapy in the majority of patients. I have reviewed cases such as this in the past, and have published extensively on the management of carotid disease.
Expert Witness Response E-009594
I perform these types of procedures up to thirty times a year. Indications for performing carotid endarterectomies depend upon the patient’ symptoms, degree of stenosis, and his general health. I can’t comment much about the case without knowing the exact percentage of stenosis and if he was “symptomatic”- in general, a 60% or greater stenosis in a patient who is symptomatic is considered appropriate for intervention. If he was without symptoms, then the question is more problematic. If a physician has a lower than 3% preoperative stroke rate, then it is acceptable to consider carotid endarterectomies if the degree of stenosis is greater than 60%, although most people would wait until it is more severe. The development of a preoperative stroke, which may have occured in this case, is a known complication of carotid endarterectomies and often a re-exploration is required, something that would be applicable here. Pre-operatively, carotid ultrasounds, CT angiography scans, MR angiography and catheter-based angiography are all appropriate imaging studies. The gold-standard remains catheter based angiography, But CTA and MRA are very close.