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Anaesthesia for Carotid Endarterectomy (CEA)

Factors Favouring Carotid Artery Stenting (CAS) vs. Carotid Endarterectomy (CEA)

• Stenting (CAS) is generally preferred in patients with significant comorbidities or challenging surgical anatomy. Endarterectomy (CEA) remains the procedure of choice in older patients and those with anatomically tortuous vessels that complicate catheter navigation. Risk trade-offs include lower MI risk with CAS and lower stroke risk with CEA.

1. Periprocedural Risks

• Myocardial Infarction (MI):
  • CAS favoured–associated with lower MI risk.
• Stroke (30 days and 4 years):
  • CEA favoured–associated with lower stroke risk.
• Death:
  • Neither procedure has a clearly superior mortality benefit.

2. Age

• < 70 years:
  • CAS favoured–better outcomes in younger patients.
• Older than 70 years:
  • CEA favoured–better outcomes in older patients.

3. Local Complications

• CAS favoured in patients at risk of:
  • Cranial nerve injury
  • Neck haematoma
  • Tracheostomy stoma interference
  • Contralateral recurrent laryngeal nerve palsy

4. Hostile Neck Anatomy

• CAS favoured when anatomy complicates surgery:
  • Restenosis after prior CEA
  • Previous neck irradiation
  • High or low carotid bifurcation
• CEA favoured if:
  • Tortuous vessel segments proximal/distal to the lesion

5. Significant Comorbidities

• CAS favoured in patients with:
  • Cardiopulmonary disease
  • General surgical risk due to comorbidity burden

NICE Pathway: Carotid Imaging and Carotid Endarterectomy for People with TIA or Non-Disabling Stroke

• Patient with suspected non-disabling stroke or TIA is identified as a candidate for carotid endarterectomy (CEA) upon specialist assessment.
• Carotid imaging should be performed within 1 week of symptom onset.

Based on Imaging

• Symptomatic carotid stenosis <50% (NASCET) or <70% (ECST):
  • Best medical treatment (BMT) only—CEA is not indicated.
• Symptomatic carotid stenosis 50–69% (NASCET) or 70–99% (ECST):
  • Best medical treatment + Refer for CEA assessment within 1 week.
  • Carotid endarterectomy should be performed within 2 weeks of symptom onset.
  • Carotid stenting is only considered in specific cases where CEA is high risk or not feasible—not routinely performed alongside CEA.

Benefits

• Improves survival and reduces the risk of disabling stroke in patients with embolic or ischaemic symptoms if stenosis >80% (ECST study). Reduces 5-year stroke and death risk by 29% in symptomatic stenosis between 50-69% (NASCET study).
• Mortality rate from stroke and myocardial infarction post-op is 5%.

Considerations

• Shared airway
• Significant hemodynamic fluctuations:
  • X-clamp: hypertension, tachycardia, increased myocardial O2 demands
  • Carotid sinus manipulation: bradycardia, hypotension
• Coexisting diseases (CAD, DM, HTN, PVD, CKD, CVD, smoking, advanced age)
• Neuromonitoring (usually EEG, cerebral oximetry, TCD, stump pressure)
• Complications:
  • CNS: CVA (ischemic/embolic), hyperperfusion syndrome, cranial nerve dysfunction
  • Cardiovascular: MI, labile BP (hypertension/hypotension)
  • Airway: hematoma, airway obstruction/loss, RLN injury
• Perioperative medication management (ASA, plavix, antihypertensives, statins)

Technique

Local Anaesthesia

• Allows neuro-monitoring of awake patient, reduces odds of death, stroke, MI, PE and local haemorrhage, but is stressful for the patient.

Neuraxial (Cervical Epidural)

• Provides good operating conditions but has a high risk of serious complications (dural puncture, epidural venepuncture, respiratory muscle paralysis).

Regional (Superficial ± Deep Cervical Plexus Block)

• Comparable efficacy with superficial only, but less post-op analgesia required with deep. Also stressful for the awake patient.

General Anaesthesia (GA)

• ETT due to turned head.
• Sevo causes less vasodilation (than Iso) and has less effect on cerebral autoregulation.
• Avoid N₂O due to increased CBF, CMR.
• Propofol decreases CBF, CMR; preserves cerebral autoregulation; causes less vasodilation than Sevo.
• Both Propofol and Sevo may be neuroprotective.
• Bailout plan if agitation or airway compromise occurs during LA/Regional.

Technique	Advantages	Disadvantages
General Anaesthesia	– Controlled ventilation and normocarbia – Airway control – Immobility	– ↓ Sympathetic & baroreceptor activity → ↓ cardiac output & BP – Intraoperative hypotension (requires vasopressors) – Postoperative hypertension
Regional Anaesthesia	– Direct monitoring of cerebral perfusion – Maintains cerebral autoregulation – Lower shunt requirement (~10%)	– Requires immobile & cooperative patient – Limited airway access – Complications: subarachnoid/epidural/intravascular injection, phrenic nerve palsy

Local Anaesthesia Technique

Positioning:

• Patient comfort: e.g., slight deck chair position, pillow under knees, sterility while avoiding drapes on the patient’s face.

Fluids:

• Empty bladder before theatre.
• Avoid excessive fluids as patients don’t bleed much.

Sedation:

• Propofol or remifentanil or dexmedetomidine.

Analgesia:

• Often require block top-up by surgeon.

Monitoring:

• Constant neurological assessment during cross-clamp (verbal communication (slurred speech), cerebral function (LOC), and motor function (grip strength)), minimal sedation.
• Arterial line in contralateral wrist.
• NIBP, sats, capnography (held in place by face mask or nasal prongs), cerebral oxygenation monitoring.

CVS Haemodynamics:

• Keep blood pressure within 20% of baseline values.

Drugs:

• Have vasopressors, inotropes, and hypotensives on standby.

Cerebral Monitoring

Cerebral Monitor	Advantages	Disadvantages
Electroencephalography (EEG)	Detects cortical ischaemia	Operator dependent, requires trained neurophysiologist, poor sensitivity, unreliable in detecting ischaemia of deeper structures
Carotid Stump Pressure	Easy technique to perform	Poor sensitivity in detecting clinically significant ischaemia
Transcranial Doppler	Allows assessment of flow in MCA, detects microemboli during dissection (>50 per hour correlates with increased incidence of postoperative neurological dysfunction)	Inadequate view in 10% of patients, poor sensitivity
Somatosensory Evoked Potentials	Theoretical advantage of monitoring cortical and deeper structures, may be useful in patients with difficult EEG to interpret due to previous stroke	Signal amplitude reduced by volatile anaesthetic agents, specialized equipment/training required
Near Infrared Spectroscopy (NIRS)	High negative predictive value (97%)	Poor positive predictive value (33%)

Anaesthetic Goals

• Maintain stable hemodynamics
• Optimize cerebral perfusion and protect myocardium
• Crisp emergence with awake patient ready for neurological exam
• Smooth emergence to minimize the risk of bleeding

Anesthetic Options:

• GA vs. regional (superficial cervical plexus block) vs. local
• Carotid artery stenting also an option if patient is unsuitable for anesthesia.

Preoperative Considerations

• Elderly patients, often with severe cardiovascular disease.
  • Most are hypertensive. BP control during CEA can be difficult.
• Determine the normal range of BP from ward charts.
  • Measure BP in both arms. Use the highest and aim for 160/90.
• Document pre-existing neurological deficits to assess new deficits more easily.
• Have vasoconstrictors (ephedrine and metaraminol) and vasodilators (GTN, labetalol) available.
• Consider cerebral monitoring techniques—there will be protocols in your unit.
• Premedication: sedative/anxiolytic, particularly if using GA.

Intraoperative Management

• 20G and 14G IV access plus an arterial line in the contralateral arm (out on an arm board).
• Monitoring: 5-lead ECG, arterial line, NIBP, SpO₂, ETCO₂.
• Maintain BP within 20% of baseline.
• During cross-clamping, maintain BP at or above baseline.
  • If necessary, use vasoconstrictors, e.g., metaraminol (10 mg diluted up to 20 mL; give 0.5 mL at a time).

General Anaesthesia for Carotid Endarterectomy:

• Careful IV induction. BP may be labile during induction and intubation.
• Administer generous doses of short-acting opioids and consider spraying the cords with lidocaine.
• Most anaesthetists use an ETT—the LMA cuff has been shown to reduce carotid blood flow, but this is of unknown significance.
• Secure the tube and check connections very carefully (the head is inaccessible during surgery).
• Remifentanil infusion, combined with superficial cervical plexus block, provides ideal conditions with rapid awakening.
• Otherwise, isoflurane/opioid technique. Maintain normocapnia. Avoid N₂O.
• Extubate before excessive coughing develops. Close neurological monitoring in recovery until fully awake.

Factors to Monitor

• (a) Cerebral Ischaemia
  • Adequate monitoring.
  • Propofol and Sevo are neuroprotective, but local allows neuro-monitoring of an awake patient.
  • Continue Aspirin, β-Blockers, and Statins—good evidence to commence statins if naive.
• (b) Myocardial Infarction
  • Monitor with 5 leads + ST analysis.
  • Haemodynamic stability.
• (c) Cranial Nerve Injury (due to surgical retraction).

Awake Carotid Procedure

• Cervical dermatomes C2–C4 may be blocked by deep and/or superficial cervical plexus block or cervical epidural.
• Patient preparation and communication are vital. A thorough explanation of the awake technique is invaluable.
• The site for the injection is the cervical transverse processes, which may be palpated as a bony ridge under the posterior border of the sternocleidomastoid.
  • For the deep block, use three 5 mL injections of 0.5% bupivacaine at C2, C3, and C4, or a single injection of 10–15 mL of 0.5% bupivacaine at C3. Reinforce this with 10 mL of 0.5% bupivacaine injected along the posterior border of the sternocleidomastoid (superficial block).
  • Avoid the deep block in patients with respiratory impairment, as they may not tolerate unilateral diaphragmatic paralysis.
  • Infiltration along the jawline helps to reduce pain from the submandibular retractor.
  • Ensure the patient’s bladder is emptied preoperatively.
  • Give IV fluids only to replace blood loss—a full bladder developing, while the carotid is cross-clamped, can be tricky to manage.
  • Sedation (e.g., propofol TCI 0.5–1 microgram/mL, remifentanil 0.05–0.1 microgram/kg/min) may be carefully employed during block placement and dissection.
  • Once dissection is complete, patient discomfort is much reduced.
  • Avoidance of sedation during carotid cross-clamping will allow continuous neurological assessment.
  • Give O₂ throughout.
  • An L-bar angled over the patient’s neck allows good access for both surgeon and anaesthetist.
  • Despite an apparently perfect regional block, ~50% of patients will require LA supplementation by the surgeon, particularly around the carotid sheath. This is reduced using remifentanil sedation.
  • Monitor the patient’s speech, contralateral motor power, and cerebration.
  • Neurological deficit presents in three ways:
    • Profound unconsciousness on cross-clamping.
    • Subtle but immediate deficit following cross-clamping, e.g., confusion, dysphasia, delay in answering questions.
    • Delayed deficit—usually related to relative hypotension.
  • Attentive monitoring of the patient is vital, particularly during cross-clamping.
    • If a neurological deficit develops, tell the surgeon who will place a shunt. Recovery should be rapid once the shunt is in place—if it is not, convert to GA.
  • Pharmacological augmentation of BP may improve cerebration by increasing the pressure gradient of the collateral circulation across the circle of Willis.
  • Increase the inspired O₂ concentration.
  • A small percentage of patients will require conversion to GA (use of an LMA is probably easiest).
  • For patients who do not tolerate regional anaesthesia, GA is the best option.

Optimization of Quality of Recovery

1. Early recognition of neurological deficit – hourly neurological assessment.
2. Blood pressure lability – arterial line, maintain SBP 100-150.
3. Cerebral hyperperfusion and ICH recognition – TCD monitoring, early CT for persistent worsening headaches.
4. Pain management – IV paracetamol ± morphine prn. Deep cervical plexus blocks require less post-op analgesia.
5. Airway compromise due to bleeding or haematoma – frequent evaluation.

Postoperative Management

• Careful observation in a well-staffed recovery room for 2–4 hours is mandatory. HDU is optimal, particularly for those patients who develop a neurological deficit.
• Airway oedema is common in both GA and regional cases, presumably due to dissection around the airway.
• Cervical haematoma occurs in 5–10% of cases. Immediate re-exploration is required for developing airway obstruction (the regional block should still be working). Remove skin sutures in recovery as soon as the diagnosis is made to allow drainage of the haematoma.
• Haemodynamic instability is common post-operatively. Hyperperfusion syndrome, consisting of headaches and ultimately haemorrhagic CVA, is caused by areas of the brain previously ‘protected’ by a tight carotid stenosis being suddenly exposed to hypertensive BP.
  • Thus, BP must be controlled.
  • Careful written instructions should be given to staff about haemodynamic management.
  • An example is:
    • If systolic BP >160 mmHg, give labetalol 5–10 mg boluses IV or a hydralazine infusion.
    • If systolic BP <100 mmHg, give colloid 250 mL stat.
    • New neurological symptoms and signs require immediate surgical consultation.
• Carotid stenting is a developing procedure for symptomatic carotid patients performed in the radiology suite, in which a stent is placed under LA into the stenotic carotid artery.
• Anaesthetic supervision may be required because of the complications, which include perioperative stroke and haemodynamic disturbances.

Hypertension Management

• Look for cause (pain, urinary retention).
• Have they taken their usual BP medications today?

First line:

• Labetolol 10 mg IV slowly every 2 minutes (max dose 100 mg).
• If BP remains elevated after 20 minutes, move to the second line agent.
• If BP lowers but then rebounds, start an infusion 50-100 mg/hr and titrate to BP.

Second line:

• Hydralazine 2 mg IV every 5 minutes (max 10 mg).
• If BP remains elevated after 25 minutes or rebounds, move to the third line agent.

Third line:

• Glyceryl trinitrate (GTN) start infusion at 5 mg/hr, increase to 12 mg/hr and titrate to BP.
• After BP agents are stopped, monitor for rebound hypertension for 2 hours.

Complications of Carotid Endarterectomy (CEA)

Category	Complication	Anaesthetic Relevance	Acute Management
Neurological	Stroke	Risk from embolism or hypoperfusion during clamping	Maintain cerebral perfusion, urgent CT brain, consult neurology/neurosurgery
	Cranial nerve injury	May affect airway (vagus, RLN), tongue movement (hypoglossal)	Supportive care, ENT referral if airway compromise, document deficits clearly
	Seizures	Often from hyperperfusion or embolism	Benzodiazepines or anticonvulsants; optimize BP, rule out intracranial bleed
	Cerebral hyperperfusion syndrome	Presents with headache, seizure, altered mental state	Strict BP control (e.g., labetalol), neuro ICU, imaging to rule out ICH
Cardiovascular	Myocardial infarction	Common in vascular patients; risk during emergence	ECG, troponins, notify cardiology, manage with oxygen, analgesia, nitrates, beta-blockers
	Hypertension / Hypotension	Affects cerebral perfusion and bleeding risk	Titrate vasodilators (e.g., labetalol) or vasopressors; target MAP 70–100 mmHg
Airway / Respiratory	Neck haematoma / airway obstruction	Surgical emergency, may present with stridor or airway collapse	Urgent decompression, call for surgical support, prepare for emergency airway
	Recurrent laryngeal nerve palsy	Risk of aspiration or airway obstruction	ENT consult, assess voice and airway, consider delayed extubation if bilateral
Local	Neck haematoma / bleeding	May cause airway compromise or compress carotid structures	Immediate decompression, reverse anticoagulation if needed, secure airway
	Wound infection	Delayed complication, more common in diabetics	Antibiotics, wound care, surgical drainage if abscess
Other	Carotid body denervation	Loss of baroreflex → BP lability	Continuous BP monitoring, use short-acting agents to titrate BP
	Contrast nephropathy (if stenting also performed)	Preand intraoperative renal injury risk	IV hydration, avoid nephrotoxic drugs, monitor creatinine post-op

Links

• Vascular physiology
• Neuroradiology
• Neuroprotection

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Past Exam Questions

Anaesthesia for Carotid Endarterectomy

a) How would you mitigate the risk of life-threatening surgical complications intra-operatively? (5)

b) What factors can be optimized to improve the quality of recovery after carotid endarterectomy? (5)

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References:

1. 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.
2. Stoneham, M. D., Stamou, D., & Mason, J. (2015). Regional anaesthesia for carotid endarterectomy. British Journal of Anaesthesia, 114(3), 372-383. https://doi.org/10.1093/bja/aeu304

Summaries:
Local anaesthesia for CEA

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© 2025 Francois Uys. All Rights Reserved.

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