Carotid endarterectomy (CEA) is a surgical procedure for treating occlusive atherosclerotic disease involving the common and internal carotid arteries. The procedure is more effective than medical management for patients with high grade stenosis (70–99%), symptomatic moderate stenosis (50-69%), or asymptomatic high-grade stenosis (≥ 60%). CEA involves making a longitudinal incision along the anterior border of the sternocleidomastoid muscle to expose the common, internal, and external carotid arteries as well as the carotid sinus. The carotid artery is then opened and the atherosclerotic plaque is removed. Opening of the carotid artery requires occlusion of the proximal common carotid and distal internal and external carotid arteries, which requires adequate collateral flow from the contralateral common carotid artery or placement of an internal shunt between the proximal common carotid and the distal internal carotid arteries. On removal of the atherosclerotic plaque, the media and adventitia of the arteries may be re-approximated or a graft may be used. These grafts are typically synthetic, but vein grafts are occasionally used.
Evaluate plaque location and adequacy of collateral flow with carotid angiograms prior to surgery
Preoperative ECG is useful as perioperative MI is the most common major postoperative complication. Uncontrolled hypertension or diabetes, as well as recent MI are reasons to delay the case.
ABGs, Spirometry, and CXRs are useful only if otherwise indicated from the H&P
Anti-platelet agents (typically aspirin) are typically initiated preoperatively and continued until the day of surgery to prevent perioperative thromboembolic complications.
Labs and studies
No unique laboratory evaluation is necessary
Operating room setup
Patient preparation and premedication
Premedication in CEA may complicate the immediate postoperative evaluation for stroke or TIA.
Use of preoperative benzodiazepines and opioids should be limited.
If a discussion of the operation and safety steps is inadequate to alleviate the patient's fear, a small dose of midazolam is preferred to opioid premedication.
Regional and neuraxial techniques
Superficial cervical plexus blocks + supplemental field blocks by surgeon
Deep cervical plexus blocks are now avoided due to concomitant Horner's Syndrome, phrenic nerve block, and recurrent laryngeal nerve injuries
Patients receiving regional anesthesia for CEA have decreased ICU times and may have decreased need for surgical shunts. Regional anesthesia for CEA, however, does not provide cerebral protection afforded by general anesthesia and it makes conversion to GETA more challenging should the need arise.
Monitoring and access
Standard ASA monitors
Arterial line is required as it allows prompt vasopressor titration in response to changes in blood pressure, particularly if induced-hypertension is being used during carotid clamping.
Invasive blood pressure monitoring is particularly useful during the immediate postoperative period to monitor for cerebral hyperperfusion syndrome.