Preoperative Considerations

• coronary artery disease likely
• hypertension
• transient ischemic attacks
• neurologic deficits, neurologic status

Goals

• maintain CPP, CBF
• especially during cross-clamp of carotid artery:
  • depend on collateral flow or
  • temporary surgical shunt
• stump pressure (pressure in carotid artery distal to clamp) is neither sensitive nor specific monitor of adequacy of collateral circulation

Anesthesia

• Choice of anesthesia, local or general, has not been shown to alter morbidity or mortality
• Local
  • cervical plexus block plus regional infiltration
  • allows monitoring cerebral function via conversation with patient
  • lack of airway control
  • need to manage complications of cerebral ischemia and confusion
  • regional anesthesia may be inadequate
• General
  • IV induction, N₂O/O₂/inhaled agent +/- opioids +/- muscle relaxants
  • isoflurane may provide element of cerebral protection *
  • thiopental, 3-6 mg/kg, immediately before carotid artery clamping (but no clear improvement in morbidity or mortality)
  • maintain blood pressure within patient's own normal limits
  • may need phenylephrine infusion, or, less likely, vasodilator infusion
  • arterial line may be helpful
  • P_aCO₂ normal recommended
  • efficient, smooth emergence
  • neurologic evaluation

Postoperative problems

• lability of blood pressure
• airway compression due to hematoma at operative site
• loss of carotid body function
• myocardial infarction
• cerebrovascular accident
• continuous arterial blood pressure monitoring may be helpful
• hypertension may require labetalol or nitroprusside
• hypotension may reflect carotid sinus hyperactivity

CEA Aneurysm Tumor Apnea Cord References
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