Carotid Endarterectomy (CEA)
Patient phenotype
Typically 60–80, atherosclerotic, often with CAD + HTN + DM + COPD + hyperlipidemia. Symptomatic (TIA, amaurosis fugax) or asymptomatic ≥ 70% stenosis.
Procedure
Neck incision over the SCM, expose carotid bifurcation, clamp common-internal-external carotid, open + endarterectomize the plaque, close with patch. ~90 min. Some centers do regional (cervical plexus block) for awake monitoring; others GA.
Anesthetic plan
GETA with strict BP control: induction + intraop MAP within 20% of preop baseline. Cerebral oximetry or somatosensory-evoked potentials for ischemia monitoring. A-line essential.
Setup
- ·5-lead ECG with ST analysis
- ·A-line pre-induction (radial, contralateral arm)
- ·Two large-bore PIVs
- ·Cerebral oximetry (NIRS) probes both forehead
- ·Phenylephrine + nitroglycerin infusions ready
- ·Heparin + protamine drawn
Biggest concerns by phase
Cardiac risk stratification — these patients have CAD
CEA patients have a ~50% incidence of significant CAD. Periop MI is the leading cause of CEA mortality. Optimize: continue β-blocker + statin + ASA. Recent NSTEMI / unstable angina = postpone if possible.
Tight BP control during induction + intubation
Goal MAP within 20% of baseline (often baseline is high — don't normalize). Smooth induction with fentanyl + propofol + lidocaine. Avoid hypotension → ischemic stroke. Avoid hypertension → plaque rupture, MI.
Cerebral perfusion during cross-clamp
Monitor cerebral oximetry — drop > 20% from baseline = at-risk hemisphere. Maintain MAP 20% above baseline during clamp time. Surgeon may use shunt if oximetry drops or if baseline contralateral disease. Awake CEA = best monitor (patient talks, moves contralateral hand).
Carotid sinus reflex — bradycardia + hypotension
Surgeon manipulating carotid sinus → vagal reflex → bradycardia + hypotension. Tell surgeon when it happens; they'll inject local around sinus or stop. Atropine 0.5 mg ready. Glycopyrrolate slower onset.
Smooth wake-up + immediate neuro exam
Goal: awake, neuro-intact, hand-movement, follows commands within minutes of extubation. Avoid cough/buck (risks suture-line bleed). Lidocaine pre-extubation. Document neuro exam comparing pre + post-op.
Hyperperfusion syndrome + neck hematoma
Hyperperfusion: brain unaccustomed to high flow, can hemorrhage. Treat HTN aggressively (target ≤ 140/90). Neck hematoma: airway emergency, may need rapid re-intubation + return to OR. Stridor or expanding swelling = open clips at bedside.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
Mid-CEA, the surgeon clamps the internal carotid. Cerebral oximetry on the operative side drops from 65% to 38%. What's happening and what do you do?
What an examiner probes for
- ▹Recognizes inadequate cross-collateral perfusion via Circle of Willis
- ▹First moves: raise MAP 20% above baseline (phenyl/NE), 100% FiO₂, lighten anesthetic
- ▹Communication: tell surgeon — they may shunt
- ▹Anticipates postop: stroke risk, neuro exam paramount
Patient is extubated, opens eyes, follows commands with right hand. Two minutes later they suddenly become hypertensive (210/110), tachycardic, and a left-arm weakness appears. What do you do?
What an examiner probes for
- ▹Recognizes possible hyperperfusion vs. evolving stroke vs. ICH
- ▹Aggressive BP control — nicardipine, esmolol
- ▹STAT CT head, neurology consult
- ▹Maintains airway readiness — likely re-intubation if obtundation
Sources
- Miller's Ch 65
- ASA Practice Advisory: Periop Stroke
- AHA/ASA CEA Guidelines
Anatomy reference
Sourced reference images. 4 matches for "carotid artery neck cerebral".
