Carotid Stenting
Patient phenotype
Symptomatic carotid stenosis (TIA/stroke), or asymptomatic high-grade in poor surgical candidates. Heavy CAD/PAD/COPD comorbidity.
Procedure
Femoral access, catheter to carotid, embolic protection device, balloon dilatation, stent deployed. ~1-2 hours. Off-floor (IR or hybrid).
Anesthetic plan
MAC + light sedation (need awake neuro check during stent deployment). GA reserved for uncooperative or anatomy needs. Strict BP control around deployment.
Setup
- ·A-line
- ·PIV
- ·Atropine + glyco at hand (carotid sinus reflex)
- ·Vasopressor + vasodilator infusions
- ·Off-floor monitoring
Biggest concerns by phase
Continue DAPT + statin
Aspirin + clopidogrel both continued. Statin for plaque stabilization. Beta-blocker continued.
Carotid sinus reflex during balloon dilatation
Stretch of carotid sinus → vagal stim → bradycardia (sometimes asystole), hypotension. Atropine 0.4-1 mg or glyco 0.2-0.4 mg ready. Some surgeons inject local around carotid.
Awake neuro monitoring
Light sedation (small midaz + remi or dex) — patient should follow commands. Watch for new deficit during stent deployment (embolic event).
Hyperperfusion syndrome
Post-stent: previously hypoperfused brain suddenly normalized → hyperperfusion → cerebral edema, ICH. Strict BP control: SBP < 140 post-procedure × 24-48h.
Stroke surveillance
Frequent neuro checks. New deficit → urgent imaging + neuro consult.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
70-yo M with prior MI + EF 30%, COPD, recent TIA, 90% L ICA stenosis. Carotid stenting (CEA too high risk). Plan?
What an examiner probes for
- ▹MAC for awake neuro check
- ▹Continue DAPT + statin
- ▹Atropine ready for sinus reflex
- ▹Strict BP control + hyperperfusion prevention
- ▹Postop neuro surveillance
Sources
- Miller's Ch 70
- AHA Carotid Revascularization Guidelines
Anatomy reference
Sourced reference images. 4 matches for "carotid artery neck cerebral".
