CAROTID ENDARTERECTOMY

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Carotid endarterectomy is a surgical procedure performed to reduce the risk of stroke by removing plaque and fatty deposits from the carotid artery, which is one of the primary arteries supplying blood to the brain. This procedure is typically recommended for patients with significant carotid artery narrowing (stenosis) caused by atherosclerosis, which can lead to reduced blood flow to the brain and an increased risk of stroke.

 

The surgery involves the following steps:

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1. Anesthesia: The patient is given either general anesthesia, which puts them to sleep, or local anesthesia, which numbs the area around the carotid artery.

2. Incision: The surgeon makes an incision along the front of the neck on the side where the blocked artery is located.

3. Clamping: The surgeon clamps the carotid artery above and below the plaque-filled area to temporarily halt blood flow.

4. Opening the artery: The surgeon makes a small incision in the artery to expose the plaque.

5. Plaque removal: The surgeon carefully removes the plaque from the artery's inner lining.

6. Repair: The surgeon stitches the artery back together, using a patch if needed to widen the artery and prevent narrowing.

7. Unclamping: The clamps are removed, and blood flow is restored through the artery.

8. Closing the incision: The surgeon closes the skin incision with sutures or staples.

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After the surgery, patients may experience temporary neck pain, hoarseness, or difficulty swallowing. The recovery period varies depending on the patient's overall health, but most people can return to their normal activities within a few weeks.

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Carotid endarterectomy is just one treatment option for carotid artery stenosis. In some cases, less invasive procedures, such as carotid angioplasty and stenting, may be considered.

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                                                   Anesthetic Implications for Carotid Endarterectomy

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Anesthesia type: General, Regional

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Airway: Endotracheal tube

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Preoperative:

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• Optimize the patient’s coexisting conditions

• Perform full neurological assessment

• Document neurologic deficits

• Careful use of benzodiazepines

• Placement of an arterial line 

• Large bore IV x2

• The Circle of Willis anatomy is normal in 50% of people

• Careful evaluation of the cardiovascular status

• If BP is different in the two arms,  it should be measured in the arm with the highest values

• Normally elderly patients with CAD

• An awake patient is the most reliable method for assessing neurology 

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Intraoperative:

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• Maintain hemodynamic stability to ensure cerebral perfusion

• Minimize cardiac depression

• Cerebral protection by decreasing CMRO2

• Patients may also experience large blood pressure swings (due to carotid sinus stimulation or loss of baroreceptors)

• Keep blood pressure higher to perfuse collateral areas

• Ischemic areas lose normal autoregulation and their functioning becomes pressure dependent

• Maintain normocapnia

• Cerebral monitoring can be done to assess cerebral perfusion

• EEG, somatosensory evoked potentials (SSEP), transcranial Doppler, and near infra-red spectroscopy (NIRS)

• The anesthetic choice should not interfere with any neurologic monitoring

• Heparinization prior to carotid artery clamping

• Heparin and protamine should be available 

• Maintaining MAP 10–20% higher than baseline is recommended during carotid clamping

• Position: Supine, arms tucked, head slightly extended and tilted away from operative side

• Secure the ETT opposite from the operative side

• EBL 50-150 mL

• Duration 2-3 hours

• Total carotid occlusion time should be documented in the chart

• The arterial line transducer can be placed at the level of the head to assess cerebral perfusion pressure (CPP)

• Stump pressure may be transduced

• Stump pressure (pressure distal to clamp) evaluates the adequacy of cerebral perfusion

• Stump pressure is created by the backflow from the contralateral carotid artery across the circle of Willis

• Surgical stimulation to carotid receptors can cause bradycardia and hypotension

• Atropine and glycopyrrolate should be available

• Surgeon can apply lidocaine to carotid bulb to improve hemodynamic flunctuation

• A carotid shunt may be placed by surgeon

• The carotid shunt is a method used to bypass the carotid clamp and maintain ipsilateral perfusion during carotid cross-clamping

• Most anaesthetic agents reduce the cerebral metabolic rate

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Postoperative:

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• Smooth and rapid emergence

• Maintain stable hemodynamics

• Avoid coughing and bucking

• Perform neurological examination

• Pain management

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Complications:

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• Hyperperfusion syndrome

• Cerebral edema

• Postoperative hypertension

• Seizures

• Baroreceptor regulation loss

• Myocardial ischemia

• Postoperative stroke

• Hematoma formation

• Airway compression

• Vocal cord paralysis (recurrent laryngeal nerve damage)

• Cranial nerve injury

• Infection

• Loss of ipsilateral chemoreceptor carotid body function

• Tension pneumothorax

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Sources:

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Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. 

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Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). 

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Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult.

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Zdrehuş C. Anaesthesia for carotid endarterectomy - general or loco-regional? Rom J Anaesth Intensive Care. 2015 Apr;22(1):17-24. PMID: 28913451; PMCID: PMC5505327.

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