Eversion Carotid Endarterectomy Periprocedural Care

Updated: May 17, 2022
  • Author: Jovan N Markovic, MD; Chief Editor: Vincent Lopez Rowe, MD  more...
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Periprocedural Care

Patient Preparation

Anesthesia

Both local/regional anesthesia and general anesthesia have been used for eversion carotid endarterectomy (eCEA); which approach is preferable in this setting remains a matter of debate. Data from several randomized trials comparing regional and general anesthesia, including an international multicenter randomized trial of 3526 patients from 24 countries, have shown that the choice of anesthesia does not independently predict the outcome of the operative procedure. [28, 29, 30, 31]

Subsequent analysis of data from the same database showed that in patients for whom either anesthetic approach was clinically indicated, cost-effectiveness analysis favored local anesthesia. [32] Ultimately, the surgeon, in consultation with the anesthesiologist and the patient, must make the final decision regarding the best anesthetic management in each case.

If local or regional anesthesia is selected, mild sedation may be administered, but the patient must be alert enough to be evaluable for neurologic changes. Usually, two or three simple questions are agreed on with the patient in advance and then repeated during carotid cross-clamping. Drapes may be suspended above the patient’s head on a Mayo stand to create more space for the patient.

Generally, regional anesthesia is optimal in calm patients with slender and mobile necks; it may be less successful in patients who are claustrophobic or anxious, have high lesions or immobile necks, or have previously undergone carotid endarterectomy (CEA).

Positioning

The patient is placed in the supine position with the neck hyperextended (see the image below). Once the neck is hyperextended, the head is rotated 15-20º away from the side of the lesion to face the opposite side. This maneuver moves the mandible superiorly, exposes the mediolateral aspect of the neck, and opens up the angle of access to the anterior neck triangles on the side of the lesion. Folded sheets may be placed under the shoulders, or a tape may be placed across the patient’s forehead and secured at the edges of the table.

Patient is placed in supine position with hyperext Patient is placed in supine position with hyperextension of neck. Head is rotated 15-20° away from operating side to face contralateral to side of lesion. This maneuver is used to move mandible superiorly, to expose mediolateral aspect of neck, and to open up angle of access to anterior neck triangles at side of lesion.

Proper positioning is important because excessive hyperextension of the neck can tighten the sternocleidomastoid muscle and restrict the mobility of the common carotid artery (CCA) and the carotid bifurcation, thereby making exposure of the lesion more difficult. Another reason for avoiding extensive hyperextension of the neck is to ensure that the internal jugular vein (IJV) remains lateral, rather than anterior, to the carotid artery.

Because cervical arthritis is prevalent in the age group for which eCEA is most commonly indicated, the neck must be carefully manipulated and slowly hyperextended at the craniocervical joint. Introducing some degree (10-20°) of reverse Trendelenburg is useful for maximizing exposure, reducing venous pressure and congestion, and minimizing bleeding.

After proper positioning, a topical antiseptic agent is carefully applied to the neck with minimal pressure (to avoid dislodging emboli from the carotid plaque). The operating area is cordoned off with four sterile drapes (see the image below). Incorporating the ear lobe and mastoid process (superiorly) and the neck midline (medially) and the sternoclavicular joint (inferiorly) into the surgical field is essential. A single weight-based dose of an intravenous antibiotic (cefazolin) is administered within 1 hour of making the incision.

Operating area is cordoned off with 4 sterile drap Operating area is cordoned off with 4 sterile drapes. It is essential to incorporate ear lobe and mastoid process (superiorly), neck midline (medially), and sternoclavicular joint (inferiorly) into surgical field.
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Monitoring & Follow-up

If the patient is afebrile, neurologically intact, and hemodynamically stable, he or she may safely be discharged on postoperative day 1. Before discharge, the neck is examined and the Blake drain removed. The patient is instructed to return if any problems develop and given detailed discharge instructions. A routine follow-up visit is scheduled 4 weeks after the operation; this visit should include carotid duplex evaluation.

The 2018 guidelines from the Society for Vascular Surgery (SVS) recommended that after CEA, surveillance with duplex ultrasonography (US) should be carried out at baseline and every 6 months for 2 years and annually thereafter until the patient is stable. [33] ​ The first duplex study should be done soon after the procedure (preferably ≤ 3 months) to establish a posttreatment baseline. Surveillance should be maintained at some regular interval (eg, every 2 years) for the life of the patient.

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