Anaesthesia for carotid surgery

Abstract

Stroke is a leading cause of morbidity and mortality and may be preceded by a transient ischaemic attack (TIA). 20% will have a carotid stenosis caused by atheromatous plaque which can be removed by carotid endarterectomy, reducing the risk of further stroke.

Risk of stroke is highest in the immediate period following TIA and surgery is recommended within 7 days. The benefits of surgery are highest in those with more than 70% stenosis. Preoperative optimization is limited by the urgency of surgery, but assessment focuses on associated cardiac and respiratory comorbidities including blood pressure control.

Carotid endarterectomy can be performed under general or regional anaesthesia (with superficial or intermediate cervical plexus blocks) and while large trials have shown no significant difference in outcomes, there are advantages and disadvantages to each. Intraoperative blood pressure control and care with the effects of positioning is required. Smooth emergence with early neurological assessment is the aim with general anaesthesia. The main risk of surgery is postoperative stroke but there is no high-quality evidence for intraoperative shunting or cerebral monitoring in reducing this.

Other postoperative complications include cardiac ischaemia, hypertension including cerebral hyperperfusion syndrome and airway compromise due to oedema/haematoma.