1. 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

2. 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.

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

4. 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 , n=23,237
All CEA in California , n=51,331 MD CA
Stroke
0.73%
0.45%
Death
0.54%
0.48%

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

6. 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

7. 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

8. Reports of LRA vs. GA: Meta-Analysis

9. 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

10. GALA Trial: LRA vs. GA

11. 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

12. CEA Exposure and Arteriotomy

13. 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

14. 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

15. 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.

16. 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

17. CEA Closure: Patch vs. Eversion

18. 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

19. 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

20. 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

21. 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