Bleeding following surgery on the carotid artery: the ‘second phase management’ concept!

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Surgery to treat a severely diseased carotid artery is a relatively safe operation in almost 90-95% of patients. The remaining 5-10% will be at risk of death or stroke if their immediate postoperative complications are not treated promptly and effectively. The three most common examples of such second-phase complications include ‘malignant’ hypertension, significant bleeding, and a flap-related or hypoperfusion-related intraoperative stroke. The management of such complications, or what we can call the ‘second-phase management concept’ can save a further 8-9% of patients’ life, leaving 1-2% to havea rather ‘unavoidable’ serious complications (stroke or death).

Postoperative bleeding occurs in 1-4.5% of patients. The UK national audit on carotid surgery has shown that bleeding occurred in 3.4% of cases, of which 2.5% returned to theatre. This resulted in 0-0.1% contribution to death or stroke, reflecting the efficiency of managing such complications in experienced hands of UK surgeons. Bleeding occurs more commonly due to a slipping of the surgical knot from a vein branch, especially following a strong cough (Valsalva manoeuvre). It can also occur from the dissection surfaces due to an excessive effect of anticoagulation medications (see newest guidelines on anticoagulation here). Finally, the bleeding can originate directly from the artery due to stitch-line bleeding or a rupture of the artery wall or the patch.

Cases from the author’s experience:

Over the last 10 years of vascular experience, first as a specialist registrar then as a consultant surgeon, the author has attended few cases of bleeding post carotid surgery; almost all of them were treated promptly and recovered successfully from a rather immediate life-threatening condition. One case was a carotid surgery performed in a tertiary referral centre, whereby the bleeding occurred immediately upon waking the patient up from general anaesthetic. The surgeon (one of the most experienced in the world) was still scrubbed up when the drain suddenly filled up with fresh blood. The surgeon opened the wound up instantly to find a ruptured back wall of the carotid artery. He controlled the proximal then distal bleeding and re-inserted the shunt. He then used a jump graft to repair the artery.

The second case occurred following resection of a carotid body tumour. The raw area was oozing significantly in the postoperative period. Nevertheless, the patient didn’t need to go back to theatre. The third case was a patient who has been on warfarin for atrial fibrillation and developed a classical TIA due to a severe stenosis in his right common carotid artery. He was put on aspirin and clopidogrel by the stroke team. One week later, he underwent a carotid endarterectomy after stopping the warfarin and the clopidogrel for 48h. The surface was oozing significantly intraoperatively and he required the use of different haemostatic agents (bioglue, fibrillar, etc.). These were enough to stop the bleeding and recover the patient. However, upon reintroducing therapeutic clexan 48h postoperatively, the patient developed expanding haematoma. He was taken immediately to operating theatre where stitch lines and raw surfaces were found to be significantly oozing. More importantly, the trachea was significantly deviated and oedematous. The bleeding was stopped and the patient required admission to ITU and 48h intubation. He recovered following that with no further evidence of active bleeding.

Take home message: don’t be fearful of Vascular complications; they do and they will occur! Instead, be ready to take further actions to save the patients who will only make a successful recovery if a prompt and wise decision had been made by the operating surgeon.