Carotid endarterectomy is an procedure performed to remove plaque from the endothelium of the common carotid artery in order to improve flow through the internal carotid and thus perfusion of intracranial structures including the brain.
Several randomized controlled trials have proven benefit of this procedure in symptomatic patients with 70-99% stenosis. Different sources quote risk of stroke or death associated with CEA as anywhere from 1 to 7%.
Anesthetic complications related to hypoperfusion during or after the procedure (i.e. stroke) may be mitigated by maintaining adequate CPP. Invasive blood pressure monitoring is indicated (arterial-line), though other monitoring devices (EEG, stump pressures) have not been shown to improve outcomes. During clamping, perfusion is solely from the Circle of Willis and most sources suggest that you must maintain MAP within 20% of baseline. Also, hypocarbia should be avoided as it that may lead to increased cerebrovascular resistance, vasoconstriction and cerebral ischemia.
The most important intraoperative complications include embolic stroke secondary to dislodgement of a carotid plaque or piece thereof, and myocardial ischemia or infarction.
Postoperative complications include stroke and MI, but also may include neck hematoma and airway compromise. Patients should be monitored for extreme changes in blood pressure during extubation and awakening, and should avoid coughing or straining to the extent possible.
According to the NASCET trial, approximately 1 in 10 CEA patients experienced some medical complication not directly related to the surgery, and “[e]ndarterectomy was ≈1.5 times more likely to trigger medical complications in patients with a history of myocardial infarction, angina, or hypertension (p < 0.05).”
Proper preoperative investigation, assessment, and optimization may mitigate some of these risks.
Finally, as the carotid bodies provide the primary respiratory drive when patients are hypoxic, a bilateral carotid endarterectomy would result in significant impairment of the hypoxic drive.
- Miller RD, Eriksson LI, Fleisher L, Wiener-Kronish JP, Cohen NH. Miller’s Anesthesia, 8th ed. Philadelphia, PA: Elsevier Saunders; 2014.
- UK NHS: CEA-Risks
- Paciaroni M, Eliasziw M, Kappelle LJ, Finan JW, Ferguson GG, Barnett HJ. Medical complications associated with carotid endarterectomy. North American Symptomatic Carotid Endarterectomy Trial (NASCET). Stroke. 1999 Sep;30(9):1759-63.
Defined by: Ben Moses, MD