The ABC’s Of Carotid Endarterectomy: Does Type of Anesthesia and Technique Matter? John. J Ricotta, MD, FACS Professor of Surgery, Georgetown University Chair of Surgery, Washington Hospital Center CRT 2012

I have no real or apparent conflicts of interest to report. John J. Ricotta, MD I have no real or apparent conflicts of interest to report.

Introduction As a prophylactic operation, CEA should have the lowest possible complication rates Results of CEA have improved significantly over the last 3 decades -10% S/D in 1980’s to 1-2% S/D in 2010 Refinements in patient selection and technique are responsible for this improvement

Deaths after Carotid Endarterectomy Trends in the in-hospital stroke rate following carotid endarterectomy In California and Maryland S.L. Matsen et al J Vasc Surg 2006; 44:488-95 Observational study of administrative data In-hospital stroke & mortality All CEA in Maryland 1994-2003, n=23,237 All CEA in California 1999-2003, n=51,331 MD CA Stroke 0.73% 0.45% Death 0.54% 0.48%

Complications after CEA Death – primarily Cardiac causes patient selection anesthetic management Stroke – Primarily Technical avoid embolization maintain cerebral perfusion avoid thrombosis

Patient Selection Avoid intervention in “high risk” asymptomatic patients – SAPPHIRE Detect and treat Occult myocardial ischemia in all asymptomatic patients prior to intervention Stabilize all medical conditions in symptomatic patients prior to intervention – CEA is an elective, sometimes urgent but never emergent procedure

Anesthetic Management Hemodynamic Instability occurs in about 20% of CEA patients and some kind of hemodynamic intervention may be required in up to 50% Patients with poorly controlled hypertension are most at risk Swings in BP are associated with both cardiac and cerebrovascular complications LocoRegional Anesthesia (LRA) may have a role in these patients. Also allows selective shunting

Reports of LRA vs. GA: Meta-Analysis

GALA Trial (Lancet 2008) Compared LRA and GA in 3500 pts No difference in stroke or death rate between LRA and GA “Intervention” for control of BP was more common in GA that LRA Conclusion: LRA will only be of benefit in patients where intraoperative control of BP is likely to be difficult

GALA Trial: LRA vs. GA

CEA Technique Wide Exposure: Digastric – Omohyoid avoid traction injury Identify and protect CN VII, IX, X, XII “No touch” , distal clamp first Arteriotomy in the Midline of the ICA Visualize Endpoints – tacking sutures as needed Avoid redundancy – eversion, plication Routine Patch

CEA Exposure and Arteriotomy

Cerebral Perfusion Routine vs. Selective Shunt <10% of pts will require augmentation of CBF during CEA – recent stroke, contralateral occlusion, VBI symptoms Most symptoms develop within minutes of cross clamping – 4 min of ischemia is OK No data to show benefit of selective vs. routine shunt – meta analysis Shunt has its own complications – emboli, flaps, poor visualization of endpoints

When to Shunt? Recent symptoms Evidence of poor distal perfusion back pressure ( 25?, 40?, 50?) End organ dysfunction – EEG, SSEP Local Anesthesia Most pts do not require a shunt, if abnormalities occur check systemic BP Occasionally place shunt AFTER CEA and prior to closure

Shunting during CEA Personal Perspective Place shunt under control, never force always back bleed When in doubt – DO NOT SHUNT Shunt can be removed if necessary to allow complete plaque removal Shunt is rarely needed once CEA is in progress.

Preventing Thrombosis: Arterial Closure Prospective Randomized data favor Routine Patch Closure over Primary Closure for standard CEA for reduced stroke rate and reduced restenosis Patch Material immaterial Eversion = Patch Closure Eversion useful for redundancy, high lesions

CEA Closure: Patch vs. Eversion

Preventing Thrombosis: Completion Imaging Routine Completion Imaging has been advocated to reduce complication rates - the significance of most abnormalities remains unclear With complete plaque removal and appropriate anti thrombotic Rx routine imaging is not needed. Selective imaging with difficult cases/poor visualization

Preventing Thrombosis: Antithrombotic Rx Thrombosis is generally worse than bleeding in this situation CEA creates a raw surface that attracts platelets and thrombi ASA plus Dextran vs. ASA plus Plavix Heparin reversal is optional There is increase bleeding risk but reoperation for bleeding is well tolerated

Summary Perioperative Management and meticulous technique are critical to maximize the outcomes of CEA - Appropriate Patient Selection and preparation - Selective use of Regional Anesthesia - Optimal Exposure - Complete Plaque Removal under vision - meticulous closure

Summary Routine Patch Closure or Eversion technique should be performed The indications for shunting and completion imaging are individualized Aggressive perioperative antithrombotic therapy is helpful Stroke / Death Rates <2% should be expected