What is the procedure for a carotid endarterectomy?

From the Guidelines

Carotid endarterectomy should be performed as early as possible, ideally within 14 days after symptom onset, in patients with acute ischemic stroke or TIA and ipsilateral extracranial internal carotid artery stenosis of 70-99%, if the morbidity/mortality risk of the surgical team is < 6% 1. The procedure for a carotid endarterectomy involves several key steps:

• The patient is placed under general or local anesthesia with sedation to ensure comfort and minimize pain during the procedure.
• The surgeon makes an incision along the front of the neck, carefully exposing the affected carotid artery.
• The artery is clamped to stop blood flow temporarily, and the surgeon opens the artery to remove the plaque deposits from the arterial wall.
• In some cases, a temporary shunt may be placed to maintain blood flow to the brain during the procedure.
• Once the plaque is removed, the surgeon closes the artery with sutures or a patch graft (using synthetic material or a piece of vein).
• The incision is then closed with sutures or staples. Some important considerations for the procedure include:
• The use of antiplatelet therapy, such as aspirin, before and after the procedure to reduce the risk of stroke and other cardiovascular events 1.
• The administration of antihypertensive medication as needed to control blood pressure before and after the procedure 1.
• The documentation of clinical neurological examination findings within 24 hours before and after the procedure 1.
• The potential benefits and risks of the procedure, including the risk of stroke, nerve injury, bleeding, or infection, and the importance of careful patient selection and surgical team expertise 1.

From the Research

Procedure Overview

The procedure for a carotid endarterectomy can be performed using either regional or general anesthesia techniques, each with its own set of considerations and outcomes.

Anesthesia Techniques

• Regional anesthesia allows for neurological monitoring of the awake patient during surgery, enabling immediate detection of any neurological issues 2.
• General anesthesia, on the other hand, requires the patient to be unconscious throughout the procedure, but can also be used with a cooperative patient technique that allows for neurological monitoring 2.
• The choice between regional and general anesthesia may depend on various factors, including patient characteristics and surgeon preference 3, 4.

Surgical Procedure

• The surgical procedure involves removing plaque buildup from the carotid artery to prevent stroke 5.
• The use of regional cerebral oxygen saturation (rSO2) and middle cerebral artery velocity (MCAv) can help monitor the patient's neurological status during the procedure 5.
• Supervised training of general surgery residents in carotid endarterectomy performed on awake patients under regional block is safe and desirable 6.

Outcomes and Considerations

• Studies have shown that there is no significant difference in outcomes, including stroke, myocardial infarction, and death, between regional and general anesthesia 3, 4.
• However, regional anesthesia may be associated with shorter operative and anesthesia times, as well as a higher likelihood of discharge the next day 4.
• Patient and surgeon satisfaction with the cooperative patient general anesthesia technique has been reported to be high 2.