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1. Anesthesia for Anesthesia for
Carotid Artery SurgeryCarotid Artery Surgery
Christopher Kochan, M.D.Christopher Kochan, M.D.
Brooke Army Medical CenterBrooke Army Medical Center

2. Topics for discussionTopics for discussion
Carotid artery diseaseCarotid artery disease
Carotid endarterectomy procedureCarotid endarterectomy procedure
Preop, intraop, postop anesthetic issuesPreop, intraop, postop anesthetic issues

Regional vs. General anesthesiaRegional vs. General anesthesia

Cerebral monitoringCerebral monitoring
Future: CEA vs CASFuture: CEA vs CAS

3. Carotid Artery DiseaseCarotid Artery Disease
1.2 million TIAs or strokes per year1.2 million TIAs or strokes per year
150,000 deaths each year from stroke150,000 deaths each year from stroke

3rd leading cause of death3rd leading cause of death

4. Carotid artery diseaseCarotid artery disease
Atherosclerosis Atherosclerosis

bifurcation of the bifurcation of the
common carotid arterycommon carotid artery

5. Carotid artery diseaseCarotid artery disease
Atherosclerosis Atherosclerosis

or origin of the or origin of the
internal carotid internal carotid
arteryartery

6. Carotid artery diseaseCarotid artery disease
Ischemia usually Ischemia usually
due to due to emboli emboli

hypoperfusion hypoperfusion
10% CVAs10% CVAs
Collateral flowCollateral flow

Circle of WillisCircle of Willis

Extacranial anastamosisExtacranial anastamosis

Watershed Watershed
communicationscommunications

7. Carotid artery diseaseCarotid artery disease
Poor collaterals?Poor collaterals?

5 FOLD5 FOLD increase in increase in
periop. strokeperiop. stroke

8. Carotid artery diseaseCarotid artery disease
Management optionsManagement options

Medical ManagementMedical Management
BP controlBP control
Antiplatelet drugsAntiplatelet drugs

Carotid Endarterectomy (CEA)Carotid Endarterectomy (CEA)

Carotid artery Stenting (CAS)Carotid artery Stenting (CAS)

9. High-grade symptomatic patientsHigh-grade symptomatic patients ( (70-9970-99%)%)

NNorthorth A Americanmerican S Symptomaticymptomatic C Carotidarotid E Endarterectomyndarterectomy T Trial rial (1992) - (1992) -
Long term stroke rateLong term stroke rate
Surgical - 9%Surgical - 9%
Medical - 26%Medical - 26%

EEuropeanuropean C Carotidarotid S Surgeryurgery T Trial rial
- Long term stroke rate- Long term stroke rate
Surgical - 2.8%Surgical - 2.8%
Medical - 16.8%Medical - 16.8%
Medical Mangement vs. Carotid EndarterectomyMedical Mangement vs. Carotid Endarterectomy

10. Asymptomatic patientsAsymptomatic patients ( (60-9960-99%)%)

AAsymptomatic symptomatic CCarotid arotid AAtherosclerosis therosclerosis SStudy tudy
- 5 year risk for stroke- 5 year risk for stroke
Surgical - 5.1%Surgical - 5.1%
Medical - 11%Medical - 11%
Medical Mangement vs. Carotid EndarterectomyMedical Mangement vs. Carotid Endarterectomy

11. Perioperative Morbidity/MortalityPerioperative Morbidity/Mortality
RisksRisks

StrokeStroke (3-5%) (3-5%)
Risk based upon presenting symptomsRisk based upon presenting symptoms
Stroke>TIA>AsymptomaticStroke>TIA>Asymptomatic
Timing of surgery after acute strokeTiming of surgery after acute stroke

4-6 weeks?4-6 weeks?

Myocardial InfarctionMyocardial Infarction (0-4%) (0-4%)
Greatest risk for periop/late mortalityGreatest risk for periop/late mortality

12. Preoperative EvaluationPreoperative Evaluation
CADCAD - high incidence ~66% - high incidence ~66%

Unstable CAD?Unstable CAD?
Staged procedure Staged procedure

CEA first -> MICEA first -> MI

CABG first -> StrokeCABG first -> Stroke
Combined CABG/CEA Combined CABG/CEA

higher stroke/death rates than CABG alone.higher stroke/death rates than CABG alone.
HTNHTN - -

Where does their BP tend to run? Where does their BP tend to run?

13. Preoperative EvaluationPreoperative Evaluation
DMDM

Associated with higher cardiac mortalityAssociated with higher cardiac mortality
CRICRI

Associated with higher risk for stroke/deathAssociated with higher risk for stroke/death
Aspirin therapy - continue it! Aspirin therapy - continue it!

Decreased rate of periop strokesDecreased rate of periop strokes

14. Anesthetic ManagementAnesthetic Management
GoalsGoals

Optimize perfusion to the brainOptimize perfusion to the brain

Minimize myocardial stressMinimize myocardial stress

Rapid anesthetic recoveryRapid anesthetic recovery
MonitorsMonitors

A-line is a mustA-line is a must

PA Cath / TEE depending on CADPA Cath / TEE depending on CAD

15. Intraoperative IssuesIntraoperative Issues
Blood pressureBlood pressure

bradycardia / hypotensionbradycardia / hypotension

surgical manipulation of carotid sinussurgical manipulation of carotid sinus

ablated with LA infiltrationablated with LA infiltration

16. Intraoperative IssuesIntraoperative Issues
Blood pressure controlBlood pressure control

Maintain high-normal BPMaintain high-normal BP
autoregulation in ischemic areas gone (maximally dilated)autoregulation in ischemic areas gone (maximally dilated)
rely on perfusion pressure for CBFrely on perfusion pressure for CBF

17. Intraoperative IssuesIntraoperative Issues
Blood pressure controlBlood pressure control

Severe contralateral stenosisSevere contralateral stenosis
BP 10-20% above baseline during cross-clampBP 10-20% above baseline during cross-clamp

Short acting agents preferredShort acting agents preferred

18. Intraoperative IssuesIntraoperative Issues
Blood pressure controlBlood pressure control

Severe contralateral stenosisSevere contralateral stenosis
BP 10-20% above baseline during cross-clampBP 10-20% above baseline during cross-clamp

Short acting agents preferredShort acting agents preferred

19. Intraoperative IssuesIntraoperative Issues
Blood pressure control - resuming flowBlood pressure control - resuming flow

Hypertension - Hypertension -

damage/LA infiltration of Carotid Sinusdamage/LA infiltration of Carotid Sinus

Hypotension/bradycardiaHypotension/bradycardia

flow restoration to Carotid Sinusflow restoration to Carotid Sinus

20. Intraoperative IssuesIntraoperative Issues
Cerebral protectionCerebral protection

BP maintainanceBP maintainance

GA GA
Shunt everyoneShunt everyone
Shunt with EEG changes*Shunt with EEG changes*

Regional AnesthesiaRegional Anesthesia
Shunt for mental status Shunt for mental status
changeschanges

MS changes - 4-6x stroke rateMS changes - 4-6x stroke rate

21. Intraoperative IssuesIntraoperative Issues
Cerebral protectionCerebral protection

HyperglycemiaHyperglycemia

BG <250BG <250

Animal studies reducesAnimal studies reduces
ischemiaischemia

Carbon Dioxide Carbon Dioxide
Hypercarbia Hypercarbia

no advantageno advantage

steal phenomenon potentialsteal phenomenon potential
HypocarbiaHypocarbia

Cerebral vasoconstrictionCerebral vasoconstriction

22. Postoperative ConcernsPostoperative Concerns
HypertensionHypertension

Increased risk of strokeIncreased risk of stroke

20% of postop strokes are hemodynamic in nature20% of postop strokes are hemodynamic in nature

Increased risk of hyperperfusion syndromeIncreased risk of hyperperfusion syndrome
headache / seizure headache / seizure
intracranial hemmhorage (0.4-2%)intracranial hemmhorage (0.4-2%)
Risks - hypertension and severe stenosisRisks - hypertension and severe stenosis

Goal: Normotensive via short acting agentsGoal: Normotensive via short acting agents

23. Postoperative ConcernsPostoperative Concerns
HypotensionHypotension

Carotid sinus baroreceptor hypersensitivityCarotid sinus baroreceptor hypersensitivity

Almost as common as postop hypertensionAlmost as common as postop hypertension

Can lead to MI or cerebral ischemiaCan lead to MI or cerebral ischemia

Treat promptly with short acting agentsTreat promptly with short acting agents

24. Postoperative IssuesPostoperative Issues
Cranial nerve dysfunctionCranial nerve dysfunction

watch out for prior contralateral CEAwatch out for prior contralateral CEA
Carotid body denervationCarotid body denervation

Unilateral - Impaired vent. Response to hypoxemiaUnilateral - Impaired vent. Response to hypoxemia

Bilateral - Loss of response to hypoxia or hypercarbiaBilateral - Loss of response to hypoxia or hypercarbia
Serious respiratory depression with narcoticsSerious respiratory depression with narcotics
Airway compromise (neck hematomas)Airway compromise (neck hematomas)
Perioperative MI/Stroke Perioperative MI/Stroke

25. Controversial IssuesControversial Issues

26. Cerebral ischemia monitorsCerebral ischemia monitors
Awake patientAwake patient - Gold Standard - Gold Standard
EEGEEG - - Neurologic changes correlate with EEGNeurologic changes correlate with EEG

High rate of false positives (increased shunting)High rate of false positives (increased shunting)
SSEPSSEPss - - Not any better than EEG, but more complexNot any better than EEG, but more complex
Cerebral oximeteryCerebral oximetery - High false positive rate - High false positive rate
Jugular venous O2Jugular venous O2 - no good data yet. - no good data yet.

27. Cerebral ischemia monitorsCerebral ischemia monitors
Stump PressureStump Pressure

Poor sensitivity/specificityPoor sensitivity/specificity

28. Regional vs. General AnesthesiaRegional vs. General Anesthesia
Most studies are not prospective, randomized trialsMost studies are not prospective, randomized trials
Low incidence of complications makes the likelihood of Low incidence of complications makes the likelihood of
proving benefit difficultproving benefit difficult

Need a prospective trial with 2000 patients to show 50% benefit Need a prospective trial with 2000 patients to show 50% benefit
at 95% confidence intervalat 95% confidence interval
Some indication from a number of retrospective studies Some indication from a number of retrospective studies
that regional anesthesia may reduce:that regional anesthesia may reduce:

Cardiac morbidity/mortality and stroke rateCardiac morbidity/mortality and stroke rate

Definitely a lower incidence of shunt rate in regional anesthetics.Definitely a lower incidence of shunt rate in regional anesthetics.

29. Regional vs. General AnesthesiaRegional vs. General Anesthesia
General Anesthetic issuesGeneral Anesthetic issues

EEG or shunt neededEEG or shunt needed

Concern for LMA useConcern for LMA use
Significant reduction in carotid bulb lumen size and Significant reduction in carotid bulb lumen size and
blood flow in normal patientsblood flow in normal patients

Postop hypertension more common than regionalPostop hypertension more common than regional

30. Regional Anesthetic IssuesRegional Anesthetic Issues

Superficial cervical plexus blockade as effective as deep and Superficial cervical plexus blockade as effective as deep and
superficial blockadesuperficial blockade

Not uncommon to need supplementation by surgeonNot uncommon to need supplementation by surgeon

Postop hypotension more common than general anesthesiaPostop hypotension more common than general anesthesia
Regional vs. General AnesthesiaRegional vs. General Anesthesia

31. Regional vs. General AnesthesiaRegional vs. General Anesthesia
Regional Anesthetic issuesRegional Anesthetic issues

Patient selectionPatient selection

Procedure selection (high carotid lesions)Procedure selection (high carotid lesions)

Surgeon selectionSurgeon selection

SedationSedation

Potential for seizurePotential for seizure

32. 22
33
44
Deep Cervical Plexus BlockDeep Cervical Plexus Block
Landmarks:
•Mastoid
•C6 transverse process
•Line 1cm posterior to this

33. Deep cervical plexus blockDeep cervical plexus block
5cc of local 5cc of local
anesthetic at anesthetic at
each leveleach level
Complications:Complications:

SeizureSeizure

LA toxicityLA toxicity

Phrenic nerve Phrenic nerve
blockadeblockade

Dural punctureDural puncture

34. Superficial Cervical Superficial Cervical
Plexus BlockadePlexus Blockade
Lesser occipital n.
Greater auricular n.
Transverse cervical n.
Supraclavicular n.

35. Superficial Cervical Superficial Cervical
Plexus BlockadePlexus Blockade
5cc of local 5cc of local
anesthetic at the anesthetic at the
level of the level of the
cricoid posterior cricoid posterior
to the SCM...to the SCM...

36. 5cc of local 5cc of local
anesthetic anesthetic
superiorly along superiorly along
the border of the the border of the
SCM...SCM...
Superficial Cervical Superficial Cervical
Plexus BlockadePlexus Blockade

37. And 5cc of local And 5cc of local
anesthetic anesthetic
inferiorly along inferiorly along
the border of the the border of the
SCM.SCM.
Superficial Cervical Superficial Cervical
Plexus BlockadePlexus Blockade

38. Carotid Artery Stenting (CAS)Carotid Artery Stenting (CAS)
Prospective trials underwayProspective trials underway
Minimal sedation neededMinimal sedation needed
Similar rates of Perioperative stroke/death (100 pt. Trial)Similar rates of Perioperative stroke/death (100 pt. Trial)

6.5% surgical vs. 8% nonsurgical in symptomatic/asymptomatic 6.5% surgical vs. 8% nonsurgical in symptomatic/asymptomatic
patientspatients
Similar complication rateSimilar complication rate

3 groin hematomas requiring surgery in nonsurgical vs. 3 neck 3 groin hematomas requiring surgery in nonsurgical vs. 3 neck
hematomas requiring surgery in surgical patientshematomas requiring surgery in surgical patients

39. Questions?Questions?