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ANAESTHESIA FOR CAROTID ENDARTERECTOMY

ANAESTHESIA TUTORIAL OF THE WEEK 56
2ND JUNE 2007

Dr. Richard Hughes, Anaesthetic specialist registrar

Dr. Richard Telford, Anaesthetic consultant
Royal Devon & Exeter Hospital, UK

E mail: [email protected]

Case study and questions

Before reading the tutorial read the following case study and try to answer the
questions. The answers can be found within the body of text.

A 66 year old man presents for carotid endarterectomy (CEA). He suffered an

embolic stroke six weeks ago. Carotid duplex scanning has demonstrated
that the left internal carotid artery is 95% occluded.

• What particular points would you like to cover in your pre-operative

history?
• Which systems will you examine?
• The patient asks you if there are any risks of the operation. What do you
tell him?
• Should surgery be performed so soon after a stroke?

Past medical history reveals well controlled chronic obstructive pulmonary disease
(COPD) and hypertension. He denies angina or symptoms of peripheral vascular
disease. His hypertension is well controlled on atenolol, slow-release nifedipine and
frusemide. He is also taking aspirin. He has made a complete recovery from his
recent stroke. You discuss surgery under both general and local anaesthesia. The
patient decides that he would like to remain awake.

What options are available for anaesthetising the surgical field for carotid
endarterectomy? What are the side effects and complications of these?
Should he take all his usual medications on the morning of surgery?
Would you prescribe any sedative premedication?
Is routine invasive arterial blood pressure monitoring justified?

The patient arrives in the operating suite and after establishing monitoring you
perform superficial and deep cervical plexus blocks.

What are the anatomical landmarks for these techniques?

Describe how you would perform a deep cervical plexus block.

Surgery commences and after about fifteen minutes the patient complains of pain in
his jaw.

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What would you do?

On application of the carotid cross clamps the patient loses consciousness and begins
to obstruct his airway.

How would you manage the situation?

Following appropriate treatment, the patient regains consciousness and surgery

continues uneventfully. You are called to recovery half an hour after completion of
surgery as the patient is complaining of a headache. His blood pressure is 195/110.

• Would you treat his hypertension?

• If he became drowsy what investigations would you request?

The headache resolves and just as he is about to be transferred to the ward, he

complains of difficulty breathing. On examining him, you notice a large swelling
beneath the incision.

• What is your immediate management?

• How will you manage his airway for surgical re-exploration?

Background KEY POINTS

• Surgery is performed to reduce future risk
Atherosclerotic disease is widespread in the of stroke.
western population, with increasing • CEA should be performed as soon as
possible after a TIA or stroke.
prevalence in the developing world. Risk • Vascular patients with high associated co-
factors include familial predisposition, morbidity.
smoking, diabetes, hypercholesterolaemia and • High risk surgery; combined death and
hypertension. major stroke risk is 2-5%.
• Carotid cross clamping risks ipsilateral
Surgery to relieve atherosclerotic obstruction cerebral ischaemia.
• Significant cardiovascular morbidity – use
of the carotid arteries was first performed at invasive arterial blood pressure
St. Mary’s Hospital, London, in 1954. Since monitoring and control blood pressure
then, evidence for its effectiveness has pharmacologically.
accumulated (CEA is the most studied • Awake surgery allows direct neurological
operation in surgical history). In 2003 nearly monitoring.
140,000 carotid endarterectomies were • Suitable local anaesthetic techniques
include cervical epidural, superficial and
performed in the USA (Halm). deep cervical plexus blocks and local
infiltration by surgeon.
The aim of CEA is to prevent embolic stroke. • Consider formal neurological monitoring
As with any prophylactic operation, careful when using general anaesthesia.
evaluation of the relative benefits and risks of • Continue neurological and invasive
the procedure is required. Peri-operative haemodynamic monitoring into the post-
operative period.
combined mortality and major stroke risk is 2 • If re-exploration is necessary this should
– 5%. This is lowest for asymptomatic be done under local anaesthesia
disease, intermediate for TIA and highest for
completed stroke.

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The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the
European Carotid Surgery Trial (ECST) are both large randomized class 1 studies
which have defined current indications for carotid endarterectomy. NASCET found
that for every six patients treated with CEA, one major stroke would be prevented at
two years (i.e. a “number needed to treat” (NNT) of six) for symptomatic patients
with a 70 – 99% stenosis. Symptomatic patients with less severe carotid occlusion
(50 – 69%) had a smaller benefit, with a NNT of 22 at five years (Barclay). In
addition, co-morbidity adversely affects the outcome; patients with multiple medical
problems have a higher post-operative mortality and hence benefit less from the
procedure. The European asymptomatic carotid surgery trial (ACST) found that
asymptomatic patients may also benefit from the procedure, but only the group with a
high grade stenosis (greater than 80% stenosis in men; unclear in women). For
maximum benefit patients should be operated on soon after a TIA or stroke,
preferably within the first month.

Depending on definition and rigorousness of assessment, the reported peri-operative

stroke rate can be as high as 35% (Rothwell). The majority of peri-operative strokes
are caused by factors outside of the anaesthetist’s control such as intra-operative
embolism and thrombosis at the endarterectomy site (Jacobowitz). Twenty per-cent
of peri-operative strokes are due to haemodynamic failure, a factor often readily
manipulated by the anaesthetist (Whitney).

CEA necessitates a period of carotid artery cross clamping. This may cause cerebral
ischaemia if collateral blood flow via the circle of Willis is inadequate. In such
patients cerebral perfusion is maintained by the use of a surgically inserted shunt to
bypass the isolated section of carotid artery. The use of a shunt is associated with
increased risk of embolic phenomena and arterial dissection.

Avoidance of cerebral ischaemia is essential. Various techniques are available for

monitoring cerebral perfusion. Clinical observation of an awake patient is the gold
standard monitor of cerebral function. In patients receiving general anaesthesia
monitoring options include carotid artery stump pressure, middle cerebral artery blood
flow trans-cranial Doppler analysis, near infrared spectroscopy,
electroencephalography (EEG) and somatosensory evoked potentials. None of these
techniques are entirely reliable.

Local versus general anaesthesia for CEA.

A Cochrane review in December 2003 found only limited evidence from randomized
controlled trials (seven studies, 554 patients). This showed reduction in incidence of
post-operative wound haematoma with local anaesthesia (no difference in mortality or
stroke risk). However, these were small, under-powered studies. Meta analysis of
non-randomized studies (with questionable methodology) suggests reduction in death,
stroke, myocardial infarction and respiratory complications (Rerkasem).

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Perceived advantages of an “awake” technique are:

• Gold standard cerebral function monitoring

• Lower shunt insertion rate
• Improved haemodynamic stability
• Earlier detection and treatment of complications
• Intact cerebral autoregulation
• Lower re-exploration rate
• Less post-operative anxiety for surgeon and anaesthetist
• Less postoperative pain
• Useful for patients in whom general anaesthesia is undesirable, such as those
awaiting heart valve surgery or coronary artery bypass grafting.
• Shorter hospital stay

However, CEA is currently performed routinely under general anaesthesia in many

centres with excellent results. Proponents of this technique argue its advantages
including tight arterial carbon dioxide control, cerebral protection afforded by volatile
anaesthesia and avoidance of the need for emergency airway control if the patient
loses consciousness. It has also been argued that some surgeons feel more
comfortable operating on an anaesthetised patient. A UK based multi-centre
randomized controlled trial comparing general with local anaesthesia for carotid
surgery (the “GALA” trial) is approaching its target of 3000 patients. When
published, its findings will hopefully provide more reliable guidance as to the optimal
anaesthetic technique.

Local anaesthetic techniques

Blockade of the second, third and possibly fourth cervical dermatomes is required for
surgery. This can be achieved by various techniques; cervical epidural, superficial
and deep cervical plexus blocks (alone or in combination) and local infiltration by the
surgeon. There have been no differences in outcome demonstrated between these
techniques.

Cervical epidural

Although this technique is not familiar to most anaesthetists, it has found favour in a
few areas, in particular France. A midline approach using the “hanging drop” method
may be used followed by insertion of an epidural catheter, test dose and then 10 –
15ml of 0.5% bupivacaine with or without fentanyl 50 – 100mcg. However, this
approach risks significant and frequent side effects and complications. Commonly
observed problems are hypotension, bradycardia and alterations in respiratory
function. The reported dural puncture rate is 0.5% and respiratory failure requiring
intubation occurs in around 1%. These risks are unacceptable when safer techniques
are available.

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Superficial cervical plexus block

The four cutaneous branches of the cervical plexus emerge from behind the
sternocleidomastoid muscle (SCM) at its mid-point (Erb’s point).

These nerves supply the area

from the clavicle to the jaw line
anteriorly and to the mastoid
process posteriorly. Classical
superficial cervical plexus
block involves subcutaneous
infiltration of 5-10ml of local
anaesthetic along the posterior
border of SCM around its
midpoint. A modified or
intermediate cervical plexus
block involves puncturing the
investing fascial layer before
10-20ml of local anaesthetic is
injected.

Conventional teaching is that local anaesthetic injected deep to the investing fascia of
the neck cannot block the roots of the cervical plexus due to the impenetrable layer of
deep cervical fascia. However, a recent cadaveric study demonstrated that an
injection of methylene blue deep to the investing fascia did reach the nerve roots (JJ
Pandit). This supports the observation that carotid surgery can be performed with the
intermediate cervical plexus alone.

Deep cervical plexus block

The classical approach to a deep cervical plexus block (DCPB) was to perform
separate injections at C2, C3 and C4. The single injection technique, described by
Winnie, is simpler and equally effective. The aim is to deposit local anaesthetic on
the roots of the cervical
plexus. The interscalene
groove is identified at the
level of the superior curnu
of the thyroid cartilage
(C4) by moving the
fingers laterally from
sternocleidomastoid. A
25-50mm short beveled
regional block needle is
inserted medially, caudally
and dorsally toward the
contralateral elbow. This
angulation minimizes the
risk of needle

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advancement between the transverse processes of the cervical vertebrae and

inadvertent vertebral artery or intrathecal injection. The needle should be advanced
until contact with bone (transverse process of C4) is felt and 10ml of local anaesthetic
injected after careful aspiration. The plexus is superficial, often only 10-20mm deep
to the skin.

The phrenic nerve, recurrent laryngeal nerve and stellate ganglion are also commonly
blocked by a deep cervical plexus block. It is contra-indicated in patients with severe
respiratory disease.

The mandibular branch of the trigeminal nerve sometimes contributes to innervation

of the surgical site, particularly in patients with a high carotid bifurcation. This can
result in discomfort from the retractor placed under the jaw. Local anaesthetic
infiltration subcutaneously along the jaw line or an inferior alveolar nerve block have
been shown to help in these patients. More than 50% of patients will require direct
supplementation of local anaesthesia by the surgeon around the carotid sheath despite
cervical plexus block. This is due to pain fibres running with the sympathetic nerves
which are not always covered by cervical plexus block.

Local anae sthetic infiltration

The operation can be performed under local anaesthetic infiltration by the surgeon.

Pre-operative assessment

• Careful assessment of cardiovascular co-morbidity is required although

functional cardiovascular investigations are not usually required. Blood
pressure must be adequately controlled pre-operatively. The blood pressure
must be documented.
• Assess suitability for surgery under local anaesthesia. Contra-indications
include patient refusal and movement disorders such as Parkinson’s disease.
Assess the patient’s ability to lie in a semi-recumbent position for two to three
hours.
• Enquire about any respiratory impairment, including exercise tolerance. The
phrenic nerve is almost always blocked when performing a deep cervical
plexus block, which may precipitate respiratory failure in those with
precarious lung function. DCPB should not be performed on such individuals.
• Contralateral recurrent laryngeal nerve palsy should also be identified (hoarse
voice, history of thyroid surgery) as this nerve is susceptible to surgical
damage and may be blocked with local anaesthetic infiltrated by the surgeon.
Complete airway obstruction may result from bilateral palsy.
• Make a note of anti-anginal, anti-hypertensive and respiratory medication.
• All patients should be taking a statin and aspirin unless contra-indicated.
• A careful explanation of the procedure including neurological monitoring will
help reduce anxiety and improve compliance.
• Warn the patient they may feel some intra-operative discomfort such as
toothache or earache. An analogy to dental surgery under local anaesthetic is
often helpful.
• Document pre-existing neurological deficits meticulously so that new ones
may more easily be assessed.

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• 12 lead ECG, full blood count, urea & electrolytes and group & save should be
performed.
• Omit diuretic on the morning of surgery unless large doses are taken for heart
failure. This may require the insertion of a urinary catheter.
• Patients taking clopidogrel require careful consideration. Its use is associated
with increased incidence of post-operative wound haematoma. However, if
discontinued peri-operatively the risk of thromboembolic coronary and
cerebral events is increased. One option is to continue clopidogrel and be
prepared to treat bleeding (for example aprotinin and platelet transfusion).
• Maintain all other cardiac medication including other anti-platelet drugs such
as aspirin and dipyridamole. Sedative pre-medication is generally avoided as
it hinders neurological assessment.
• Ensure tight glycaemic control in diabetic patients. Hyperglycaemia may
worsen any neurological deficit.
• Allow clear oral fluids up to two hours pre-operatively and ensure the bladder
has been emptied prior to leaving the ward.

Per-operative

• Minimum monitoring should include pulse oximetry, ECG, invasive blood

pressure monitoring. If available, five-lead ECG is more sensitive at detecting
myocardial ischaemia.
• The arterial cannula should be sited in the contralateral arm if possible.
• Insert one IV cannula for fluid and one for infusions (e.g. sedation)
• Maintenance of cardiovascular stability is paramount. Aim for a mean arterial
pressure at baseline or slightly higher during cross clamping. Vasoconstrictors
such as metaraminol (eg 0.5mg boluses) or phenylephrine (infuse at 1-6mg/hr)
and anti-hypertensives such as labetalol (5mg boluses or continuous infusion at
20-160mg/hour) or GTN (infuse at x-xmcg.Kg-1.min-1) should be available to
correct haemodynamic perturbations.

Management of the “awake” carotid:

• Sedation is useful for insertion of lines, siting blocks and during initial dissection
and mobilisation of the carotid artery. A target controlled infusion of propofol is
ideal. Discontinue sedation in good time prior to carotid cross clamping so that
the patient is alert enough to co-operate with neurological monitoring.
• Perform local anaesthetic blocks as described above.
• Oxygen should be administered via nasal cannulae or a nasal sponge.
• Empty the bladder pre-operatively. A full bladder intra-operatively can cause
discomfort and agitation. Intravenous fluid is rarely required.
• Use non-claustrophobic drapes to separate the surgical field from the patient’s
face.
• An experienced member of staff should be used to monitor and reassure the
patient. This is a vital role to detect neurological deficit at the earliest possible
opportunity. Monitoring should consist of assessment of contralateral motor
function (grip strength), speech and cognition (regular questioning). Neurological

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deficit may either be immediate following cross clamping or subtle and insidious,
perhaps related to relative in intra-operative hypotension.
• I.V. unfractionated heparin (3000 – 5000iu) should be given before cross
clamping of the carotid artery. Reversal of anticoagulation with protamine is
generally avoided as it is associated with increased stroke rates.
• A slow rise in arterial blood pressure is frequently observed during carotid artery
cross clamping.
• If neurological deficit occurs, consider pharmacological augmentation of blood
pressure if the patient is hypotensive.
• Ensure that the airway is unobstructed and increase
the FiO2.
• If neurological recovery does not follow, a surgical
shunt should be inserted immediately (10% of cases).
• Several types of shunt are available including Javid
and Pruitt-Inahara varieties. The latter is held in
place with inflatable balloons and has a side port
which allows shunt pressure to be transduced.
• Intra-operative conversion to general anaesthesia is
rare but may be necessary to maintain the airway if
neurological recovery does not result from shunt
insertion. Target controlled propofol infusion and insertion of a laryngeal mask
airway is an ideal technique.

Management of CEA under general anaesthesia:

• Invasive arterial blood pressure monitoring is mandatory. A balanced general

anaesthetic is used. Attempt to maintain the blood pressure close to baseline
values.
• Tracheal intubation gives a reliable airway but a Proseal laryngeal mask airway
may also be used in selected patients.
• Positive pressure ventilation is be used to ensure control of arterial carbon dioxide
tension.
• A superficial cervical plexus block will reduce intra-operative opiate requirement
and provide post-operative analgesia.
• Remifentanil infusion provides ideal titratable anaesthetic conditions with rapid
emergence allowing prompt assessment of neurological function upon awakening.

Post-operative

• Arrangements should be made for extended (4-6 hours) post-operative observation

in a suitable environment with continued close invasive haemodynamic and
neurological monitoring.
• Any patient developing post-operative neurological deficit needs immediate
surgical assessment. This should include prompt assessment of carotid artery
patency with carotid artery duplex scanning to help assess the cause of
neurological deterioration and suitability for re-exploration.
• If carotid duplex scanning is unavailable, the patient should be assumed to have

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developed carotid artery occlusion and taken back to theatre without delay.
• Oxygen should be administered overnight.
• Post operative hypertension is common. Treat any pain and ensure that a full
bladder is not the cause. Blood pressure should be controlled to below pre-
operative levels (the cerebral vasculature becomes exposed to increased pressure
and flow post-operatively). Use short acting anti-hypertensive agents such as
labetolol (5mg increments up to 100mg maximum).
• Uncontrolled hypertension may result in hyperperfusion syndrome. This occurs
because in the pre-operative state, the cerebral circulation has adapted to a
significant carotid stenosis by maximal dilatation and loss of autoregulation.
Following restoration of carotid artery patency, the abnormal vasculature is
susceptible to damage from excessive flow and pressure. Hyperperfusion
syndrome may be manifest as an occipitofrontal headache which may progress to
seizures and cerebral haemorrhage. This may be fatal.
• Bleeding causing wound haematoma occurs in 5% of cases. Occasionally this
may cause progressive airway obstruction. Supra-glottic oedema due to venous
congestion is common and may make visualisation of the larynx difficult.
• In the event of a return to theatre, re-exploration of the wound should be
performed under local anaesthesia if at all possible. The original regional block
will still be working and should be supplemented with local infiltration by the
surgeon if necessary. Airway obstruction will be rapidly alleviated by removal of
skin staples/sutures.
• Most patients are discharged the day after surgery.

Summary

Anaesthesia for carotid endarterectomy is challenging and rewarding. Firm evidence

for the best anaesthetic technique has yet to be published. Whether local or general
anaesthesia is employed both anaesthetic and surgical expertise have a significant
effect on outcome. Practice makes perfect!

Ackno wled ge m e nt s

Thank you to Dr. Alice Roberts for the use of her illustrations.

Further reading

New York school of regional anaesthesia website -

http://www.nysora.com/techniques/

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Reference s

Barclay, L. AAN Updates Guidelines on Carotid Endarterectomy Neurology.

2005;65:794-801

Halm, MR. et al, Revisiting the appropriateness of carotid endarterectomy.Stroke

2003;34(6):1464-1471

Jacobowitz GR et al. Causes of Perioperative Stroke after Carotid Endarterectomy:

Special Considerations in Symptomatic Patients Ann Vasc Surg. 2001;15:19-24

Kim GE et al. The anatomy of the circle of Willis as a predictive factor for intra-
operative cerebral ischemia (shunt need) during CEA. Neurol Res 2002;24:237-40

Rerkasem K, Bond R, Rothwell PM. Local vs general anaesthesia for carotid

endarterectomy. The Cochrane Database of Systematic Reviews 2004, issue 2. Art
No CD000126

Rothwell PM, Warlow CP.

Is self-audit reliable? Lancet 1995;346:1623

Stoneham M, Oxford handbook of Anaesthesia. Oxford University Press. Chapter

16;321-323

Steneham, MD, Knigton JD. Regional anaesthesia for carotid endarterectomy Br

JAnaesth 1999;82: 910-19

Whitney EG et al. Inadequate cerebral perfusion is an unlikely cause of

perioperative stroke Ann Vasc Surg. 1997;11:109-14

Winnie AP et al. Interscalene cervical plexus block: a single-injection technique

Anesth Analg. 1975 May-Jun;54(3):370-5.

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