Carotid Endarterectomy: Surgical Steps and Perioperative Management
Preoperative Preparation
Antiplatelet therapy should be initiated or continued with aspirin 75-325 mg daily, with consideration of adding a single 75 mg dose of clopidogrel the night before surgery to reduce postoperative embolization. 1, 2, 3
Medication Management
- Aspirin 81-325 mg daily should be administered before surgery and continued perioperatively 1, 3
- Single dose of clopidogrel 75 mg given the night before surgery (in addition to aspirin) reduces high-grade postoperative embolization from 3.2% to 0.4% 2
- Beta-blockers should be continued or initiated perioperatively, offering up to a 10-fold reduction in myocardial infarction risk, though high-dose regimens should be avoided 4
- Statins provide up to 3% absolute reduction in stroke incidence following CEA and should be continued 4
- Resume all cardiovascular medications (antihypertensives, statins, diabetes medications) postoperatively 1
Anesthesia Considerations
- Local or general anesthesia can be used based on patient and surgeon preference 5
- Avoid excessive sedation to facilitate continuous neurological monitoring 1
Intraoperative Steps
1. Anticoagulation
- Unfractionated heparin administered to maintain activated clotting time between 250-300 seconds 1
- Bivalirudin may be used as an alternative, eliminating need for activated clotting time monitoring 1
2. Continuous Monitoring
- Electrocardiogram and blood pressure monitoring throughout the procedure 1
- Neurological assessment of consciousness level, speech, and motor function by physician or circulating nurse 1
- Document neurological status within 24 hours before and after surgery 6
3. Surgical Technique
- Arteriotomy performed (longitudinal approach when temporary shunt needed) 5
- Endarterectomy with plaque removal 5
- Arteriotomy closure by direct suture or patch angioplasty 5
- Completion angioscopy to assess technical adequacy 2
4. Hemostasis Management
- Partial heparin reversal with protamine (up to 50 mg) after arteriotomy 5
- Additional individual sutures placed as needed for hemostasis 5
- TachoSil hemostatic sponge (9.5 cm x 4.8 cm, 1-2 sponges) may be applied topically to prevent minor bleeding without increasing infection risk 5
5. Hemodynamic Management
- Atropine 0.5-1 mg IV administered prophylactically before angioplasty/stent portion to prevent bradycardia 1
- Temporary transvenous pacemaker for persistent bradycardia 1
- Phenylephrine 1-10 mcg/kg/min or dopamine 5-15 mcg/kg/min IV for persistent hypotension 1
- Maintain systolic blood pressure <180 mm Hg to minimize intracranial hemorrhage and hyperperfusion syndrome risk 1
Postoperative Management
Immediate Recovery
- Continue neurological monitoring for new deficits 1, 6
- Blood pressure control with systolic <180 mm Hg 1
- Ephedrine 25-50 mg orally 3-4 times daily for persistent hypotension requiring extended observation 1
Antiplatelet Therapy
- Long-term aspirin or clopidogrel monotherapy after CEA 7, 3
- Low-dose aspirin (81-325 mg) preferred over high-dose (650-1,300 mg) to reduce stroke, MI, and death 3
Surveillance
- Duplex ultrasound within first month post-procedure 7
- Annual follow-up for neurological symptoms and cardiovascular risk factors 7
Critical Complications and Red Flags
Neurological Complications
- New or worsening slurred speech beyond 24-48 hours suggests perioperative stroke, hyperperfusion syndrome, or thrombotic complications requiring immediate CT/MRI 6
- Recurrent laryngeal nerve injury occurs in up to 6% of patients, causing hoarseness; speech therapy if symptoms persist >2 weeks 6
- Perioperative stroke occurs in 1.6-3.7% within 30 days 6
Hemorrhagic Complications
- Postoperative bleeding occurs in up to 8% of cases, with 4.7% requiring reoperation 5
- Clopidogrel use within 5 days independently predicts neck hematoma (8.5-fold increased odds), though most managed conservatively 8
- Patients with P2Y12 reaction units <170 have higher bleeding risk (90% with estimated blood loss ≥100 mL vs. 55.6% with PRU ≥170) 8