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Endarterectomy
Robert Y. Gumnit, MD
Director of Clinical Education
Burlington Anesthesia Associates
Carotid Endarterectomy
• Prophylactic
intervention to
prevent cerebral
infarction and
relieve symptoms of
carotid
artherosclerosis
• Stroke incidence in
USA- 160/100,000
people
Etiologies of Ischemic Stroke
• Thromboembolism from atherosclerotic
large extracranial or intracranial arteries
• Embolism from a cardiac source
• Atherosclerotic disease in small
cerebral vessels
Location of Carotid Disease
• Most likely site is at the
carotid bifurcation with
proximal internal carotid
involvement
• Carotid circulation
supplies 80 to 90% of
cerebral blood supply
• Vertebral circulation
supplies 10 to 20% of
cerebral blood supply
Distal Circulation
• Internal carotid
contributes to
anterior and middle
cerebral arteries
• 1st intracranial
branch of ICA is the
ophthalmic artery
Important Anatomic Structures
Near Carotid Dissection
• Hypoglossal nerve
• Vagus Nerve
• Recurrent Laryngeal
Nerve
• Mandibular Branch of
Facial Nerve
• Important to document
preoperative neurologic
examination
Clinical Presentation of Carotid
Disease
• Varies by site of stenosis and distal
embolization
• Part of a generalized vascular disease
• Transient Ischemic Event (TIA)/
Reversible Ischemic Neurologic
Deficit(RIND)
Transient Ischemic Events
• Sudden onset of focal neurologic deficit
which resolves within 24 hours
• Contralateral motor or sensory deficits
• Amaurosis Fugax
RIND’s
• Neurologic dysfunction greater than 24
hours but less than 2 weeks
• Important to differentiate between
carotid disease and posterior vertebro-
basilar artery disease
Posterior Circulation Symptoms
• Binocular vision loss
• Vertigo
• “Drop Attacks”
Differential Diagnosis of TIA
• Intracranial mass
• Cardiac Disease- e.g. Atrial Fibrillation,
Valvular Heart Disease,
Cardiomyopathy)
• Metabolic Encephalopathy/
Hyperglycemia
Risk Factors for Carotid Disease
• Advanced age
• Hypertension
• Diabetes
• Hyperlipidemia
• Hypercoagulable states
• Smoking
Diagnostic Imaging
• Ultrasound- 89%
detection rate
• Gold standard is
cerebral
angiography but
there is a 1%
chance of a
neurologic deficit
Choice of Therapy
• Individualized assessment of stroke risk
weighing medical management versus
risk of perioperative stroke, death, or
cardiac event
• Large multicenter trials comparing
medical versus surgical management
comparing anti-platelet therapy versus
surgery
Summary of Large Clinical Trials
• Depending on particular series, patients
with between a minimum of 50% to 70%
stenosis are candidates with ipsilateral
disease and acceptable surgical risk
• The greater the degree of stenosis, the
greater the difference in outcome
statistics compared to medical therapy
Preoperative Evaluation
• Comorbidities including advanced
vascular disease, coronary artery
disease- leading causes of
perioperative death
• Testing is useful if the only if results will
impact on actual perioperative care
Conditions Requiring Some
Workup
• Orthostatic hypotension
• Coronary artery disease
• Myocardial infarction
• Congestive heart failure
• Dysrhythmias, Implanted pacer, AICD’s
Assessment of Functional
Capacity
• DM
• Renal Insufficiency
• Pulmonary disease
ACC/AHA Guidelines
• Stepwise approach to risk assessment
• Functional capacity
• Major markers: unstable coronary
syndromes, MI, unstable angina,
uncompensated CHF, severe valvular
lesions
Intermediate Markers
• Mild angina
• Previous MI
• Compensated CHF
• DM
• Renal Insufficiency
Minor Clinical Predictors
• Advanced age
• Abnormal EKG
• Non-sinus rhythm
• Low functional capacity
• History of stroke
• Uncontrolled hypertension
• Cardiac and Long-term risks are increased in
patients unable to meet a 4-MET demand
Surgery Specific Risks
• ACC/AHA define CEA as an
intermediate risk procedure
• Risk of cardiac death or non-fatal MI
generally less than 5%
• If surgery is to be performed in
presence of high risk indicators, ACC
recommends delaying surgical for
further evaluation and treatment
Elective CEA with Intermediate
Risk Predictors
• Consider functional capacity
• Consider non-invasive testing
Indications for Further Testing
• Exercise tolerance < 4 METS
• Symptomatic valvular lesions
• Dilated or Hypertrophic Cardiomyopathy
• Hemodynamically significant
dysrhythmias
Simple Conservative Approach
• Assume presence of CAD
• Treat with medically appropriate therapy
• Coronary angiography and prophylactic
revascularization has not been shown to
reduce cardiac morbidity and should
only be used in high risk cases
Hypertension
• Most treatable preoperative risk factor for
stroke
• Reduced blood pressure decreases
probability of perioperative stroke
• Poorly controlled BP increases risk of
perioperative hemodynamic instability and
significant neurologic events
• BP meds continued right up to time of surgery
• Rapid correction of BP preoperatively not
advised
Delay Surgery if Not Emergent
• Uncontrolled hypertension
• Uncontrolled diabetes
• Uncontrolled coronary disease
Goals of Anesthetic Management
• Protect brain and heart
from ischemic injury
• Maintain hemodynamic
stability
• Ablate stimulatory and
stress response to
surgery
• Awake, cooperative
patient at end of
procedure allowing
clear neurologic
evaluation
Standard Monitoring
• ECG- Leads II, V4-5 for rhythm and S-T
segments
• Continuous arterial pressure monitoring,
arterial line
• Pulse oximetry
• Central lines generally not necessary
but should not be placed in jugular area
Perioperative ß-Blockade
• Continue for patients already on this
therapy
• Those who are not already on ß-
blockers can be started on them
immediately if there is no
contraindication for reduction of
perioperative myocardial ischemia
Choice of Anesthetic Technique
• Largely dependent on preferences of:
1. Surgeon
2. Patient
3. Anesthesia Team
• No strong data to clearly mandate any
particular method or agents
General Anesthesia for CEA
• Maintain cerebral perfusion
• Minimize myocardial work
• Rapid and smooth emergence to allow
immediate postoperative neurologic
assessment
Advantages of GA
• Allows for still, motionless patient
• Early control of airway and ventilation
• Ability to protect brain if ischemia
develops
Blood Pressure Management
• Best range is individualized to each
patient
• Risk of either myocardial or cerebral
ischemia is minimized if perfusion
pressures are maintained in the
patient’s high normal range
Choice of Induction Agent
• All available agents reduce cerebral
metabolic rate in excess of reduction of
cerebral blood flow
• Pentothal provides best protection against
focal ischemia
• Most rapid awakening with Propofol
• Etomidate has most favorable hemodynamic
profile but may worsen ischemic neurologic
injury (animal data)
Hemodynamic Response to
Intubation/ Hypertension
• Short acting narcotic
• Nitroglycerin or
Nitroprusside
Maintenance with a
Volatile Agent
• All presently clinical available agents reduce
cerebral metabolic rate
• Isoflurane has the most pronounced effect
with a minimum of myocardial depression
• Newer agents allow for more rapid
emergence ( Sevoflurane, Desflurane)
• Maintain at a lighter plane to allow rapid
emergence and an easily interpretable EEG
Hypotensive Response to
Induction
• Hypertensive patients often present in a
mildly hypovolemic state
• Phenylephrine
Maintenance Events
• Cervical incision not especially
stimulating
• Rapid changes in pulse rate and blood
pressure/ hemodynamic instability can
be frequent
• Role of short acting agents/ vasoactive
drugs
Blood Pressure Management
• Phenylephrine- α-agonist with no
direct effect on cerebral vasculature;
cerebral perfusion increased by
elevating perfusion pressure
• Br J Anaesth 2007,99:159-169
Additional Problems
• Deep blocks done alone are associated
with a higher conversion rate to GA
(2.1% vs. 0.4%)
• When deep and superficial blocks are
done together the incidence of
ipsilateral hemidiaphragmatic paralysis
is 55 to 61%
Choice of Local Anesthetic
• Bupivicaine 0.5% provides the longest
time to request for first analgesia
• Ropivicaine is probably the least
cardiotoxic
• Use the least possible amount of total
anesthetic in any case.
Outcomes: Local vs. GA
• One series of 548 cases
• Local was 10 cc lidocaine for skin, 10 cc
for platysma
• GA was thiopental with isoflurane, nitrous-
oxide/oxygen, fentanyl maintenance
• No differences in postoperative stroke or
death rate