Carotid endarterectomy in the awake patient

doi:10.1016/0002-9610(85)90026-1

The American Journal of Surgery

Volume 150, Issue 1, July 1985, Pages 159-165

https://doi.org/10.1016/0002-9610(85)90026-1 Get rights and content

Abstract

The advantages of performing carotid endarterectomy in the awake patient have been presented based on a 13 year experience. Anesthesia consisted of either local infiltration of local lidocaine or regional neck block supplemented by intravenous sedation. The principal advantages of the technique are that it is the only exact method of assessing the need for an intraluminal shunt by neurologic assessment of the awake patient during trial carotid cross-clamping, and the elimination of general anesthesia allows carotid endarterectomy to be safely performed on patients with advanced inoperable coronary artery disease and in those with chronic obstructive pulmonary disease. One hundred consecutive carotid endarterectomies have been reported with one late death and one mild, permanent neurologic deficit. These results support the belief that carotid endarterectomy can be performed with very low morbidity and mortality rates by operating on the awake patient.

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Cited by (48)

Significant Correlation between Cerebral Oximetry and Carotid Stump Pressure during Carotid Endarterectomy
2008, Annals of Vascular Surgery
Citation Excerpt :
Nonetheless, for clinicians who prefer a selective shunting technique, there are a number of available methods that have shown efficacy in evaluating the need for shunting. These include carotid artery stump pressure measurements,3,4 transcranial Doppler,5 intraoperative EEG measurements,6-8 neurological assessment in awake patients,9 and cerebral oximetry.10-14 The value of carotid artery stump pressure measurements in assessing the need for shunt was first reported in 1969 by Moore and Hall.3
Limited information on a correlation between carotid stump pressure and cerebral oximetry changes associated with cross-clamping of carotid vessels during carotid endarterectomy (CEA) prompted us to prospectively evaluate 38 consecutive CEAs in 37 patients. The authors used the INVOS-4100 cerebral oximeter to measure cerebral oximetry (cerebral oxygen saturation) before (t1) and after (t2) cross-clamping along with carotid stump pressure. All patients had CEA under general anesthesia with the routine use of a Javid shunt. Cross-clamping (t1 vs. t2) resulted in statistically significant changes (p < 0.0001) on the operated side of 6.03 units or a percent change of 9.2% when analyzed using the nonparametric signed-rank test. The nonoperated side had insignificant change (p = 0.71). Spearman correlation analysis revealed significant correlation (r = -0.63) between cerebral oximetry changes on the operated side and carotid stump pressure such that a larger change in cerebral oximetry due to cross-clamping was strongly and significantly correlated with lower carotid stump pressure. Using regression analysis, stump pressures of 25 and 50 mm Hg were predicted by cerebral oximetry changes of 28.5 or 8.8 units, respectively. This is equivalent to a percent change from baseline (t1) of 41.1% or 13.1%, respectively. Taken together, these findings suggest that cerebral oximetry can be used as an alternative to carotid stump pressure to provide noninvasive, inexpensive, and continuous real-time monitoring during CEA.
Cerebrovascular Disease: Carotid Endarterectomy
2006, Vascular Medicine: A Companion to Braunwald's Heart Disease
Cerebrovascular disease: Carotid endarterectomy
2006, Vascular Medicine
Carotid endarterectomy: Experience in 5425 cases
2004, Annals of Vascular Surgery
From 1992 to December 2002, 3967 patients (2619 males; 1348 females) with a mean age of 68.4 years (range 32–92) underwent 5425 carotid endarterectomy (CE) procedures at our institute. Neurological history was positive for stroke in 1130 cases (21%) and for transient ischemic attack (TIA) in 2121 cases (39%). In 2174 cases (40%) patients were neurologically asymptomatic or presented nonspecific symptoms. Our current clinical protocol has been designed to optimize resources and reduce complications. Some of the major features, along with the respective percentages in this series, are as follows. Duplex scanning was performed at a validated laboratory as the principal preoperative exam (86.9%). Locoregional anesthesia and neurological monitoring were performed during carotid cross-clamping (96.3%). Selective shunting was carried out with a Javid shunt (10.7%). The choice of surgical technique was made according to carotid anatomy and cerebral tolerance of cross-clamping. Those used were a standard technique (now abandoned, 12.1%), synthetic patching (46.4%), and eversion endarterectomy (41.5%). Intraoperative completion arteriography was routinely performed for eversion endarterectomy and only in dubious cases with other techniques. The option of staying in an postoperative intensive care unit (ICU) was available (selective use, 2%). In uncomplicated cases, early discharge (after 1.5 postoperative days) was conisdered safe. The overall perioperative mortality was 0.37% (20/5425). Causes of death were myocardial infarction in seven cases, ischemic stroke in six cases, hemorrhagic stroke in five cases, respiratory failure caused by cervical hematoma in one case, and wound infection in one case. Perioperative neurological morbidity was 1.31% (71/5425); there were 43 major and 28 minor strokes. In conclusion, CE is effective for stroke prevention when there is significant symptomatic and asymptomatic carotid stenosis, as low mortality and morbidity may be achieved in an experienced center. At our institute, the reduction of costs did not have negative consequences on the quality of the surgical care.
The evolution of extracranial carotid artery surgery as seen by one surgeon over the past 40 years
2003, Surgeon
Carotid endarterectomy is one of the most common vascular and neurosurgical operations. Controversies regarding its indications and safety have required several decades before general resolution, while its methodology is still debated. The first operations are described with particular emphasis on the epic successful procedure in 1954 by Eastcott and Rob. Early procedures were on patients with frank strokes with poor results. The development of carotid endarterectomy was slow because neurologists were unsure of its effectiveness and safety as the mortality and stroke results recorded by untrained surgeons were unacceptable. It was not until some 35 years after its introduction that randomised controlled trials, both in North America and Europe, defined its indications and demonstrated its benefits for both symptomatic and asymptomatic carotid stenosis. Clamping of the carotid vessels, required during endarterectomy, may result in various degrees of cerebral ischaemia. Methods to determine which patients need shunting are compared. The author has employed local neck block anesthesia since 1972, which is the only method that provides constant neurological assessment for selective shunting during carotid cross clamping. Evidence is presented showing that local anaesthesia also reduces complications of general anaesthesia, especially myocardial infarction. The technique of neck block, conventional endarterectomy and two varieties of eversion endarterectomy for carotid disease are described. Each of these techniques of endarterectomy is advantageous in certain circumstances, suggesting that vascular surgeons should ideally be proficient in each. Likewise, the management of early stroke after operation, stenotic or occluded external carotid the presence of retinal Hollenhorst plaques, and the totally occluded internal carotid, is presented. Finally, observations on some famous figures who suffered from cerebrovascular complications secondary to carotid disease and what effect it may have had on world history is discussed
Carotid endarterectomy: The "gold standard" in the endovascular era
2002, Journal of the American College of Surgeons

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^☆: Presented at the 56th Annual Meeting of the Pacific Coast Surgical Association, Monterey, California, February 17–20, 1985.

¹: From the Department of Surgery, University of California at Irvine, Irvine, California.

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Scientific paperCarotid endarterectomy in the awake patient☆

Abstract

Lancet

Am J Surg

Am J Surg

Surgical treatment of spontaneous thrombosis of the internal carotid artery in the neck. Carotid-carotideal anastomosis. Report of a case

Acta Neurol Latinoam

Carotid endarterectomy—an expression of concern

Stroke

The performance of endarterectomy for disease of the extracranial arteries of the head

Stroke

Improved results with carotid endarterectomy

Ann Surg

Scientific paper
Carotid endarterectomy in the awake patient☆