Anaesthesia for carotid surgery

Carotid endarterectomy (CEA) is a surgical procedure to prevent strokes in patients with atheromatous disease at the carotid bifurcation. The effectiveness of CEA has been established in large clinical trials. Patients should have surgery performed within 2 weeks from the onset of symptoms. This time frame presents a challenge to the anaesthetist and surgeon in risk stratifying and optimizing patients for surgery. Optimization includes blood pressure (BP) control and use of antiplatelet and lipid-lowering therapy. CEA can be carried out under general anaesthesia (GA) or regional anaesthesia (RA) with the advantages and disadvantages of both techniques discussed. Understanding surgical technique and the implications for anaesthesia is important, specifically the use of carotid shunting, eversion technique and patch angioplasty. Cerebral perfusion monitoring can be used during CEA to reduce neurological morbidity and mortality. The gold standard remains an awake patient where sensory, motor and higher mental functions can be assessed continuously. Intraoperative and postoperative management may involve haemodynamic and neurological complications such as stroke, cerebral hyperperfusion syndrome, heart failure and myocardial infarction. Compromise to the airway can occur as a result of oedema or haematoma and the latter may require exploration in theatre.