1. Carotid artery anatomy facts: 
-In 10% of people, both L and R common carotids come off of the innominate artery, making the placement of a carotid shunt harder
-The internal carotid has zero branches in the neck, the first branch of the external carotid is the superior thyroid artery. You can use this fact to identify which vessel is which after the bifurcation.
2. Nerve-related complications of carotid artery surgery
-Don't cut the vagus nerve
-Hypoglossal nerve runs around there-- if you cut it, there will be ipsilateral tongue deviation, resulting in speech alterations. They'll eventually learn to work with it and it'll get better, but their speech will never be the same.
-Glossopharygneal nerve is higher up, and you might need to dissect up if their bifurcation is high. Be careful-- if you take down CN IX, their pharynx will collapse; people describe it as impossible to swallow.
-Superior laryngeal: if you cut this, there will be vocal cord paralysis; if you cut both sides, they won't be able to breathe and they will be trach dependent for the rest of their lives. So if someone's got bilateral carotid disease, don't do them both at once; do one, then get ENT to scope them make sure vocal cords are ok, then do the other.
3. Presenting symptoms of carotid artery disease: 
-Syncope and dizziness are a frequent cause of referrals to vascular surgery, but they almost never have carotid disease as the underlying cause. Unless its an unusual case of 4-vessel disease, syncope and/or dizziness almost always due to cardiac, pulm, heme, tox, and/or volume considerations instead of carotid stenosis.
-Bruit-- listen to the heart to rule out valvular disease with neck radiation
-Neurological symptoms: TIA-style focal neuro deficits like weakness, paresthesias, speech (L carotid supplies speech centers in brain). TIAs formally are defined as <24 hours, but often will last only minutes. Amarosis fugax from embolization to opthalmic artery.
4. Diagnosis of carotid disease: 
-U/S doppler; look at the velocity, greater stenosis = higher velocity. Greater than 300 cm/s systolic 100 cm/s diastolic indicates severe disease. One thing to consider: in u/l carotid stenosis or occlusion, flow through the other artery will increase to compensate, and may give a false positive doppler.
-Confirm with CT angiogram.
5. When to operate: 
-Asymptomatic: >80% occlusion.
-Symptomatic: >50% occlusion
-Risk of triggering stroke in someone with no history of stroke: <1%. Risk in someone with a history of stroke: 4-5%. Use downstream filters during the procedure.
6. Stent vs Endarterectomy 
-SAPPHIRE trial: {NEJM, RCT, n=334} high-risk population, essentially similar outcomes. Less revision with shunt, slightly less risk of stroke (p=0.053) with stent slightly on top.
-CREST trial: {NEJM, RCT, n=2502}. At the time of procedure, stenting is associated with increased incidence of stroke or death, surgery associated with MI. 4 years after the procedure, stent is associated with slightly increased risk of stroke compared to endarterectomy.
7. Choosing your procedure: 
-Stent in people who would be harder to operate on: previous neck surgery, neck radiation, any scarring (i.e. 2/2 bad infection or abscess), VNS in place, etc.
-Bypass graft if you can't get a stent and can't do an endarterectomy: outcomes not as good long term
-Don't do a TPA catheter, you will shower downstream clots and cause TIA/stroke. (sidenote: don't use tpa cathether for upper extremity DVTs too, you will shower PEs and cause/worsen pulmonary hypertension and R heart failure)
8. During endarterectomy surgery: 
-Use a filter at the distal end of the artery to catch any small clots that may embolize during procedure
-Cut open the artery proximal to occlusion, extend to past occlusion. When you repair, don't just sew together the ends, you'll cause stenosis, make a U and use a graft to make the roof.
9. Preventing brain ischemia during surgery, two options:
-Clamp and run, with brain monitoring-- either EEG, carotid stump pressures, or do it as an awake procedure and monitor neurological status throughout
-Temporary shunt while you work
-Cochrane review cites ~700 RCT patients, shows insufficient data to definitively prefer one method to the other.
10. If your carotid is 100% occluded, 1/3 will have a major stroke, 1/3 will have a TIA, and 1/3 will be completely asymptomatic.