- Patients should be in a stable neurological condition following acute, non-disabling stroke or TIA.
- Symptomatic patients with:
- ≥50 - 99% carotid stenosis
- The benefits are considerable if >70% stenosis but only marginal if 50 - 69% stenosis
- Asymptomatic patients with:
- ≥60 - 99% carotid stenosis
- (As they are at increased risk of stroke on best medical treatment alone)
- The effectiveness of CEA in stroke prevention is greatest if performed within 48hrs of symptoms, and certainly within 2 weeks
Carotid Endarterectomy
Carotid Endarterectomy
Carotid endarterectomy appeared as an SAQ in 2019 (88% pass rate), where marks were lost on specific reasons for intra-operative haemodynamic instability.
The question was repeated as a CRQ in 2023, with a more modest 70% pass rate.
Resources
- Stroke and transient ischaemic attack in over 16s: diagnosis and initial management (NICE, 2022)
- Regional anaesthesia for carotid endarterectomy (BJA, 2015)
- General or local anaesthesia for carotid endarterectomy? (BJA Education, 2012)
- Arterial pressure management and carotid endarterectomy (BJA, 2009)
- Carotid endarterectomy (BJA Education, 2007)
- Carotid endarterectomy (WFSA, 2007)
- Carotid stenosis is implicated in 20 - 30% of strokes
- Carotid endarterectomy (CEA) aims to remove atheromatous plaque at, or around, the carotid bifurcation
- It is preventative surgery with the aim of preventing disabling or fatal stroke in those with carotid stenosis
- The combined perioperative risk of mortality or major stroke is 2 - 5% i.e. this is high risk surgery
- Pre-assessment should not cause undue delay with regards to timing of surgery
- History and examination should focus on:
- Elucidating risk factors and comorbidities associated with vascular disease e.g. HTN, DM, smoking, obesity and hyperlipidaemia
- A thorough neurological examination, as the patient will have already suffered symptoms inc. TIA or stroke
- Ascertaining as to whether there are contra-indications to a local technique, which include profound respiratory disease or contralateral recurrent laryngeal nerve palsy
- Pre-operative counselling is important in patients undergoing CEA under local anaesthesia
Investigations
- Bloods: FBC | U&E | Clotting
- ECG
- Review of TTE, which will have often been performed as part of the investigations for recent stroke
- Further investigations as dictated by individual risks and comorbidities
Optimisation
- Patients are at high risk of MACE and post-operative pulmonary complications, renal dysfunction, cognitive dysfunction and chronic pain
- Individual cardiorespiratory risk factors should be optimised within the available timeframe
- Patients are likely to be on at least aspirin monotherapy
- A single dose of 75mg clopidogrel the night before surgery is associated with a reduced incidence of post-operative thrombotic events
- There is debate about the optimal technique for CEA
- Regardless of technique, the aims are to:
- Maintain adequate oxygenation and cardiovascular stability
- Provide analgesia
- Provide good operating conditions including cerebral monitoring
- The GALA Trial (2008) did not find either general or regional technique to be superior with regards to risk of stroke, MI or mortality at 30 days
General anaesthesia | Regional anaesthesia |
Airway control | Accurate, immediate neurological assessment (gold standard) |
Optimised cerebral blood flow by manipulating PCO2/PO2 | Prevents unnecessary shunt insertion i.e. only in those demonstrating altered neurology |
Neuroprotection from reduced CMRO2 | Shorter hospital stay |
Patients tend to prefer GA | Avoids complications of GA e.g. aspiration, PONV, cardiorespiratory complications |
Allows arterial closure at a own MAP, which may reduce risk of post-operative haematoma | |
Precludes effective neurological monitoring | Complications of regional block inc. failure and need for GA or LA toxicity |
Increased use of shunts which increases risk of post-op. stroke via emboli or thrombosis | Need for sedation or conversion negates the benefits of LA |
Increased intra-op. hypotension & post-op. hypertension | Difficult airway access if needs converting |
Patient stress and pain during block increases risk of myocardial ischaemia | |
Requires cooperative patient who can lie flat and sit still |
General anaesthetic technique
- No evidence to support IV or gas induction as superior
- Generally a reinforced ETT taped to contralateral side
- Appropriate eye protection given propensity for surgeons to treat the face as an arm rest
- In general avoid long-acting opioids as may cloud post-operative neurological assessment
- Some suggestion to extubate deep (to avoid haemodynamic dyscrasia during extubation) but then stay in theatre until normal neurology is ensured
- Local anaesthetic infiltration of wound
Regional anaesthetic technique
- Block over C2 - C4 dermatomes is required
- Options include:
- Superficial cervical plexus block
- Deep cervical plexus block
- Combined superficial & deep cervical plexus block
- Cervical epidural, if you're feeling extra-spicy - it is technically challenging and has a high complication rate
- Local anaesthetic infiltration alone
- Considerations include:
- Surgical issues
- High lesions requiring high dissection or vigorous retraction can be difficult to block
- Crossover innervation by contralateral cervical plexus may require infiltration of midline LA
- The carotid artery itself (branch of glossopharyngeal n.) is exquisitely sensitive to manipulation and is difficult to block; LA injected into carotid sheath may overcome this
- Ensure appropriate pre-operative counselling about expectations
- Ensure comfortable positioning and temperature
- Use transparent drape to reduce claustrophobia
- Regular checks of cerebral function throughout, both pre- and post-cross-clamping
Monitoring
- AAGBI as standard
- Arterial line in contralateral arm
- Wide-bore access in contralateral arm
- Temperature management to ensure normothermia
- Urinary catheter often not required
Neuro-monitoring
- Carotid cross-clamping is performed both above and below the area of stenosis, which can cause cerebral ischaemia and focal neurology if there is inadequate collateral flow in the Circle of Willis
- Placement of carotid shunts can mitigate this, yet their use is associated with increased risk of post-operative stroke from thromboembolism
- Their use may be reserved for patients deemed at higher risk of cerebral ischaemia, although some surgeons place them routinely
- The gold standard is the awake patient having CEA under local anaesthetic
- The patient under GA cannot be reliably assessed for neurological deficits
- There are a number of techniques used to monitor cerebral perfusion under GA, though none are wholly reliable:
Technique | Description | Advantages | Disadvantages |
Transcranial Doppler | MCA flow measured via petrous temporal bone | Monitors for flow & emboli Can be continued post-op. |
Operator dependent Unable to generate signal in 10 - 20% |
Carotid stump pressure | Measure pressure in carotid stump beyond cross-clamp | Specific measure of cerebral ischaemia | Not very sensitive Doesn't monitor for emboli |
(p)EEG | As standard e.g. Sedline, BIS | Affected by GA Doesn't monitor for emboli Doesn't monitor deeper (non-cortical) structures |
|
SSEP | As standard | Monitors sub-cortical structures Useful if EEG abnormal |
Affected by GA Doesn't monitor for emboli No more sensitive/specific than (p)EEG |
NIRS | Measure regional saturation (rSO2) 10 - 15% deviation from baseline indicates ischaemia |
High NPV for cerebral ischaemia | Poor PPV Doesn't monitor for emboli Signal intereference |
Haemodynamic considerations
- Cardiovascular instability is very common during CEA; rapid, profound hypo- or hypertension can occur
- Cardiovascular instability can precipitate stroke, MI or heart failure
- Targets for blood pressure control include MAP within 20% of baseline, and SBP ≤170mmHg
- This should be acheived with vasoactive drugs, rather than excessive fluid administration
Pathophysiology of haemodynamic instability during CEA |
Impaired arterial pressure autoregulation following stroke |
Reduced carotid baroreceptor sensitivity due to atherosclerosis |
Effects of general or regional anaesthesia |
Effects of surgery itself |
Effects of patient comorbidities including old age, diabetes and anti-hypertensive medications |
Bleeding - clotting balance
- All patients should be taking aspirin prior to surgery ± additional clopidogrel to reduce perioperative thromboembolism
- Heparin 5,000units IV is administered just prior to cross-clamping
Cerebral steal phenomenon
- If hypercapnoea is allowed, it will cause preferential vasodilation of the non-operative side of the brain, as there is limited blood flow to the operative side due to carotid cross-clamping
- This exacerbates the already reduced perfusion to the operative side
- Prevented by ensuring normocapnoea
- Oral analgesia is typicall sufficient
- Regular neuro-observations are instigated from recovery onwards
- Patients typically go to HDU post-operatively for monitoring and management of BP, but are often readily discharged the following day
Blood pressure control
- Systolic BP should be tightly controlled, between 110mmg - 160/180mmHg
- Hypertension is common (up to two thirds of patients), especially after GA
- It is usually transient, peaking in the first few hours after surgery
- It is related to impaired baroreceptor function
- Predisposes to wound haematoma, MI and cerebral hyperperfusion syndrome
- Management of post-operative hypertension includes:
- Sitting the patient up
- Managing pain, including that from urinary retention
- Target SBP as above, or within 20% of pre-operative value
- Pharmacotherapy; first line is with ɑ-blockers or β-blockers
- Labetalol 10mg boluses every 2mins up to 100mg
- Esmolol, metoprolol, atenolol, clonidine are other options
- Direct-acting vasodilators (GTN, nitroprusside and hydralazine) and nifedipine can cause cerebral vasodilation and therefore are typically second line
- Hypotension is less common
- Excluding causes such as cardiogenic failure or hypovolaemia is imperative
- Management may involve small fluid boluses ± phenylephrine as boluses or infusion
- Overall, severe complications are rare
- Post-operative bleeding and haematoma (3 - 8%) may be airway- and/or life-threatening
- Myocardial infarction (2 - 3%)
- Recurrent laryngeal nerve injury
- Stroke can occur, with an incidence of ∽3.5%
- Most are due to intra-operative embolus or post-operative thrombosis
- 20%, however, are due to peri-operative haemodynamic instability
- Incidence is lower than the 5 - 6% rate without CEA
Cerebral hyperperfusion syndrome
- Incidence 1 - 3%
- Presents in the early post-operative period e.g. 2 - 7 days post-op.
- Risk factors include >90% stenosis, intra-operative ischaemia/emboli, operation on the second side, prolonged post-operative hypertension and reduced cerebrovascular reserve
- There is ipsilateral loss of cerebral autoregulation, causing increased ipsilateral cerebral blood flow
- Manifests as:
- Hypertension
- Ipsilateral headache
- Focal neurological deficits
- Seizures
- Management is with emergent control of blood pressure