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Figure 104-1. Algorithm Showing Evaluation and Treatment of Patient with Suspected Carotid Stenosis (Also See Chapter 108)
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Medical managementSurgical management
  • ASA + ACEI/ARB + Statin ± β-blocker
  • ≥2 events: add Clopidogrel or Dipyridamole
  • Carotid artery endarterectomy (CEA)
  • Carotid artery stenting (CAS)
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Preoperative Assessment
ImagingChartPatient
Indication
  • Degree of stenosis on operative side
Collaterals
  • Degree of stenosis in contralateral carotid and vertebral vessels
  • BP normal range (both arms)
  • Glycemic profile
  • Hb/Hct/ABO typing
  • Platelets/PT/PTT
  • No ACEI/ARB the day of surgery
  • Maintain antiplatelet agents
  • Maintain β-blockers and statins
  • Baseline neurologic status
  • Baseline cognitive function
  • Level of cooperation
  • Effect of head positioning
  • Tolerance to supine position
  • Orthostatic hypotension
  • Difficult airway predictors
  • Follow ACC/AHA guidelines for cardiac evaluation (see Chapter 7)
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Before the procedure starts:

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  • Make sure drugs, shunt, and monitoring are ready or available

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Intraoperative Equipment
Drugs and shuntMonitoring
  • Vasopressors and vasodilators
    • Available for immediate use:
    • Phenylephrine
    • Ephedrine
    • Nitroglycerin
    • Atropine
    • Available in room:
    • Clonidine 15 mcg/mL (0.5–1 mcg/kg)
    • Nicardipine 1 mg/mL (5–15 mg/h)
  • Heparin available for immediate use
  • Protamine available in room
  • Shunt available in room
  • Lidocaine available to surgeon for carotid sinus infiltration
  • SpO2, 5-lead ECG, NIBP
  • 2 IV lines (at least one large-bore)
  • Arterial line
  • A glucometer should be available
  • Central venous catheter not required.
  • If necessary (unstable patient):
    • Avoid carotid injury, favor subclavian
    • US guidance, placed by senior staff
  • Foley not required
    • Confirm patient has voided
If procedure performed under general anesthesia:
  • Confirm neuromonitoring is available
  • Measure baseline CO2 (RA) as a guide for mechanical ventilation
If procedure performed under regional anesthesia:
  • Have all equipment and drugs ready for conversion to GA if necessary
  • Monitor ventilation (ETCO2 in face mask)
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Neuromonitoring
Neuromonitor

Signs of cerebral hypoperfusion

ProsCons

Awake evaluation

New neurologic deficit

Loss of consciousness

Gold standard

Requires good cooperation

Affected by presence of preexisting neurologic deficits

EEG

Hemispheric asymmetry

Decrease in total power

Sensitive for cortical ischemia

Complete map of cortical activity

Continuous

Not very specific

Requires trained technician

SSEP

≥ 50% relative decrease (amplitude or latency)

Sensitive for subcortical ischemia

Few leads necessary

Affected by medullary dysfunction

Requires trained technician

TCD

≥ 50% relative decrease

MCA velocity < 25 cm/s

Measures MCA flow continuously

Detects microemboli

Quantifies cerebral autoregulation

TCD impossible in 5–15% of cases

Probe dislocation

Insonating jelly drying

NIRS

≥ 20% decrease in rSO2

Non-invasive, easy

Postoperative monitoring possible

Contribution of scalp perfusion

70% cortical perfusion is venous

Stump pressure

Mean pressure < 40 mm Hg

Assesses quality of collateral flowInvasive, discontinuous assessment
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Intraoperative Management
General ...

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