MetroHealthAnesthesiaCarotid Endarterectomy


Preoperative Considerations

  • coronary artery disease likely
  • hypertension
  • transient ischemic attacks
  • neurologic deficits, neurologic status

Goals

  • maintain CPP, CBF
  • especially during cross-clamp of carotid artery:
    • depend on collateral flow or
    • temporary surgical shunt
  • stump pressure (pressure in carotid artery distal to clamp) is neither sensitive nor specific monitor of adequacy of collateral circulation

Anesthesia

  • Choice of anesthesia, local or general, has not been shown to alter morbidity or mortality
  • Local
    • cervical plexus block plus regional infiltration
    • allows monitoring cerebral function via conversation with patient
    • lack of airway control
    • need to manage complications of cerebral ischemia and confusion
    • regional anesthesia may be inadequate
  • General
    • IV induction, N2O/O2/inhaled agent +/- opioids +/- muscle relaxants
    • isoflurane may provide element of cerebral protection *
    • thiopental, 3-6 mg/kg, immediately before carotid artery clamping (but no clear improvement in morbidity or mortality)
    • maintain blood pressure within patient's own normal limits
    • may need phenylephrine infusion, or, less likely, vasodilator infusion
    • arterial line may be helpful
    • PaCO2 normal recommended
    • efficient, smooth emergence
    • neurologic evaluation

Postoperative problems

  • lability of blood pressure
  • airway compression due to hematoma at operative site
  • loss of carotid body function
  • myocardial infarction
  • cerebrovascular accident
  • continuous arterial blood pressure monitoring may be helpful
  • hypertension may require labetalol or nitroprusside
  • hypotension may reflect carotid sinus hyperactivity



Send Comments to Greg Gordon MD, gjg@po.cwru.edu
Department of Anesthesiology
The MetroHealth System
2500 MetroHealth Drive
Cleveland, Ohio 44109-1998
Phone: (216) 778-4801
Last updated: