====== Carotid Endarterectomy operative technique ====== ===== Anesthesia and monitoring===== Most (but not all) surgeons monitor some parameter of neurologic function during carotid endarterectomy, and will alter technique (e.g. insert a vascular shunt) if there is evidence of hemodynamic intolerance of carotid clamping (only occurs in ≈ 1–4%). 1. local/regional anesthesia: permits “clinical” monitoring of patient’s neurologic function ((Zuccarello M, Yeh H-S, Tew JM. Morbidity and Mortality of Carotid Endarterectomy under Local Anesthesia: A Retrospective Study. Neurosurgery. 1988; 23:445–450)) ((Lee KS, Courtland CH, McWhorter JM. Low Morbidity and Mortality of Carotid Endarterectomy Performed with Regional Anesthesia. J Neurosurg. 1988; 69:483–487)) Disadvantages: patient movement during procedure (often exacerbated by sedation and alterations in CBF), lack of cerebral protection from anesthetic and adjunctive agents. The only prospective randomized study found no di erence between local and general anesthesia ((Forssell C, Takolander R, Bergqvist D, et al. Local Versus Gen eral An esth esia in Carotid Surgery. A Prospect ive Randomized Study. Eur J Vasc Surg. 1989; 3:503–509)). The multicenter, randomized controlled General Anesthesia versus Local Anesthesia (GALA) Trial ((Lewis SC, Warlow CP, Bodenham AR, Colam B, Rothwell PM, Torgerson D, Dellagrammaticas D, Horrocks M, Liapis C, Banning AP, Gough M, Gough MJ. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet. 2008; 372:2132– 2142)) found no significant differences in the prevention of stroke, MI, or death for either anesthetic technique. Subgroup analysis showed trends (not statistically significant) favoring local anesthesia for perioperative death, event-free survival at 1 year, and patients with contralateral occlusion. Local anesthesia was associated with a significant reduction of shunt insertion ((Lewis SC, Warlow CP, Bodenham AR, Colam B, Rothwell PM, Torgerson D, Dellagrammaticas D, Horrocks M, Liapis C, Banning AP, Gough M, Gough MJ. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet. 2008; 372:2132– 2142)). A Cochrane Database Review found no evidence from randomized trials to favor either anesthetic technique ((Rerkasem K, Rothwell PM. Local versus general anaesthesia for carotid endarterectomy. Cochrane Database Syst Rev. 2008. DOI: 1 0.1 002/1 465185 8. CD000126.pub3)) 2. general anesthesia, possibly including barbiturates (thiopental boluses of 125–250 mg until 15– 30 second [[burst suppression]] on EEG, followed by small bolus injections or constant infusion to ((Spetzler RF, Martin N, Hadley MN, et al. Microsurgical Endarterectomy Under Barbiturate Protection: A Prospective Study. J Neurosurg. 1986; 65:63–73)) a) EEG monitoring b) SSEP monitoring c) measurement of distal stump pressure after CCA occlusion (unreliable), e.g. using a shunt if stump pressure <25 mm Hg d) transcranial Doppler e) [[near-infrared spectroscopy]]. ---- Both [[general anesthesia]] and [[local anesthesia]] are used in the [[University Hospital Pilsen]] for [[carotid endarterectomy]] (CEA). The [[decision]] as to which anesthetic technique to use during surgery is made individually. The satisfaction of a group of 205 patients with regard to [[anesthesia]] used and their future preferences were evaluated [[prospective]]ly through a [[questionnaire]]. The reasons for dissatisfaction were assessed. CEA was performed under general anesthesia (GA) in 159 cases (77.6%) and under local anesthesia (LA) in 46 cases (22.4%). In the GA group, 148 patients (93.1%) were satisfied; 30 patients (65.2%) in the LA group were satisfied (p < 0.0001). The reason for dissatisfaction with GA were postoperative [[nausea]] and [[vomiting]] (7 patients), postoperative psychological alteration (3), and fear of GA (1). The reasons for dissatisfaction with LA were intraoperative pain (9 patients), intraoperative discomfort and [[stress]] (5), and intraoperative breathing problems (2). Of the GA group, 154 (96.9%) patients would prefer GA again, and of the LA group, 28 (60.9%) patients would prefer LA if operated on again (p < 0.0001). Overall, 172 patients (83.9%) would prefer GA in the future, and 33 patients (16.1%) would prefer LA. Overall patient [[satisfaction]] with CEA performed under both GA and LA is high. Nevertheless, in the GA group, patient satisfaction and future preference were significantly higher. Both GA and LA have advantages and disadvantages for CEA. An optimal approach is to make use of both anesthetic techniques based on their individual indications and patient preference ((Mracek J, Kletecka J, Holeckova I, Dostal J, Mrackova J, Mork J, Priban V. Patient Satisfaction with General versus Local Anesthesia during Carotid Endarterectomy. J Neurol Surg A Cent Eur Neurosurg. 2019 Apr 29. doi: 10.1055/s-0039-1688692. [Epub ahead of print] PubMed PMID: 31035296. )). ===== Position and incision ===== 1. supine, neck slightly extended and rotated slightly (≈ 30°) away from the operative side 2. the incision curves gently and follows the anterior border of the sternocleidomastoid muscle, and curves posteriorly at the rostral end 3. keep the horizontal portion of the incision ≈ 1 cm away from the mandible to avoid injury to mar- ginal mandibular branch of facial nerve (which lies in the inferior parotid gland and supplies lip depressor) due to retraction against mandible 4. retractors should not be placed deeper than the platysma to avoid injury to the recurrent laryngeal nerve, which runs between the esophagus and trachea. Blunt retractors are used to avoid internal jugular vein injury ===== Dissection ===== 1. the [[common facial vein]] (CFV) usually crosses the field over the carotid bifurcation, it is doubly ligated and divided. It leads to the [[internal jugular vein]] (IJV)