Chapter 104. Carotid Artery Endarterectomy (CEA) John G. Gaudet, MD; Yann Villiger, MD, PhD View Full Chapter Figures Only Tables Only Videos Only Print Share Email Twitter Facebook Linkedin Reddit Get Citation Citation AMA Citation Gaudet JG, Villiger Y. Gaudet J.G., Villiger Y Gaudet, John G., and Yann Villiger.Chapter 104. Carotid Artery Endarterectomy (CEA). In: Atchabahian A, Gupta R. Atchabahian A, Gupta R Eds. Arthur Atchabahian, and Ruchir Gupta.eds. The Anesthesia Guide New York, NY: McGraw-Hill; 2013. http://accessanesthesiology.mhmedical.com/content.aspx?bookid=572§ionid=42543692. Accessed April 22, 2018. MLA Citation Gaudet JG, Villiger Y. Gaudet J.G., Villiger Y Gaudet, John G., and Yann Villiger.. "Chapter 104. Carotid Artery Endarterectomy (CEA)." The Anesthesia Guide Atchabahian A, Gupta R. Atchabahian A, Gupta R Eds. Arthur Atchabahian, and Ruchir Gupta. New York, NY: McGraw-Hill, 2013, http://accessanesthesiology.mhmedical.com/content.aspx?bookid=572§ionid=42543692. 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Algorithm Showing Evaluation and Treatment of Patient with Suspected Carotid Stenosis (Also See Chapter 108)Graphic Jump LocationView Full Size|Favorite Figure|Download Slide (.ppt) ++Table Graphic Jump LocationFavorite Table | Download (.pdf) | PrintMedical managementSurgical managementASA + ACEI/ARB + Statin ± β-blocker≥2 events: add Clopidogrel or DipyridamoleCarotid artery endarterectomy (CEA)Carotid artery stenting (CAS) ++Table Graphic Jump LocationFavorite Table | Download (.pdf) | PrintPreoperative AssessmentImagingChartPatientIndicationDegree of stenosis on operative sideCollateralsDegree of stenosis in contralateral carotid and vertebral vesselsBP normal range (both arms)Glycemic profileHb/Hct/ABO typingPlatelets/PT/PTTNo ACEI/ARB the day of surgeryMaintain antiplatelet agentsMaintain β-blockers and statinsBaseline neurologic statusBaseline cognitive functionLevel of cooperationEffect of head positioningTolerance to supine positionOrthostatic hypotensionDifficult airway predictorsFollow ACC/AHA guidelines for cardiac evaluation (see Chapter 7) ++ Before the procedure starts: ++ Make sure drugs, shunt, and monitoring are ready or available ++Table Graphic Jump LocationFavorite Table | Download (.pdf) | PrintIntraoperative EquipmentDrugs and shuntMonitoringVasopressors and vasodilatorsAvailable for immediate use:PhenylephrineEphedrineNitroglycerinAtropineAvailable in room:Clonidine 15 mcg/mL (0.5–1 mcg/kg)Nicardipine 1 mg/mL (5–15 mg/h)Heparin available for immediate useProtamine available in roomShunt available in roomLidocaine available to surgeon for carotid sinus infiltrationSpO2, 5-lead ECG, NIBP2 IV lines (at least one large-bore)Arterial lineA glucometer should be availableCentral venous catheter not required.If necessary (unstable patient): Avoid carotid injury, favor subclavianUS guidance, placed by senior staffFoley not required Confirm patient has voidedIf procedure performed under general anesthesia:Confirm neuromonitoring is availableMeasure baseline CO2 (RA) as a guide for mechanical ventilationIf procedure performed under regional anesthesia:Have all equipment and drugs ready for conversion to GA if necessaryMonitor ventilation (ETCO2 in face mask) ++Table Graphic Jump LocationFavorite Table | Download (.pdf) | PrintNeuromonitoringNeuromonitorSigns of cerebral hypoperfusionProsConsAwake evaluationNew neurologic deficitLoss of consciousnessGold standardRequires good cooperationAffected by presence of preexisting neurologic deficitsEEGHemispheric asymmetryDecrease in total powerSensitive for cortical ischemiaComplete map of cortical activityContinuousNot very specificRequires trained technicianSSEP≥ 50% relative decrease (amplitude or latency)Sensitive for subcortical ischemiaFew leads necessaryAffected by medullary dysfunctionRequires trained technicianTCD≥ 50% relative decreaseMCA velocity < 25 cm/sMeasures MCA flow continuouslyDetects microemboliQuantifies cerebral autoregulationTCD impossible in 5–15% of casesProbe dislocationInsonating jelly dryingNIRS≥ 20% decrease in rSO2Non-invasive, easyPostoperative monitoring possibleContribution of scalp perfusion70% cortical perfusion is venousStump pressureMean pressure < 40 mm HgAssesses quality of collateral flowInvasive, discontinuous assessment ++Table Graphic Jump LocationFavorite Table | Download (.pdf) | PrintIntraoperative ManagementGeneral ... 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