Carotid Endarcterectomy

Question 1

CA: 2 arteries that are opened (arteriotomy) to

remove atherosclerotic plaque and repair the wall (media and adventitia).

Answer 1

The Common carotid artery (CCA) and proximal internal carotid artery (ICA)

Question 2

CA Wall repaired for carotid

Answer 2

Media and adventitia

Question 3

CA: Temporary occlusion of the

Answer 3

proximal CCA, distal ICA, external CA, and usually it’s 1
st branch the superior thyroid artery. The entire
procedure can be achieved under continued occlusion of these vessels if the collateral blood flow to the
territory supplied by the occluded internal carotid is deemed adequate

Question 4

CA: Occluded internal carotid is asssedby

Answer 4

(on the basis of intraop EEG monitoring, internal carotid artery back-bleeding, stump pressures, CBF studies, or angiography).

Question 5

CA: The order or clamping for CA

Answer 5

internal-common-external carotid (When unclamping the order is reversed).

Question 6

CA: Alternatively, an internal shunt between the

Answer 6

proximal common carotid artery and distal internal carotid artery can be placed after the arteriotomy for use during the endarterectomy.

Question 7

CA: Often a synthetic graft (e.g., Dacron) or,

Answer 7

occasionally, a vein graft, is used to reconstruct (“patch”) the arteriotomy site and increase the luminal
diameter.

Question 8

CA: Surgical time is approximately

Answer 8

3 hours.

Question 9

CA position

Answer 9

Supine position with shoulder roll, HOB elevated slightly, patient’s head is slightly extended and tilted away from
operative side.

Question 10

CA: Cardiopulmonary effects of positioning include

Answer 10

decrease FRC due to cephalad displacement of diaphragm from abdominal contents.
Aortocaval compression may occur in obese patients. Bilateral arms are tucked at patient’s side.

Question 11

CA: Secure ETT

Answer 11

Secure ETT on opposite side of the mouth than surgical side. Standard monitoring and arterial line is routine.

Question 12

CA: Stump pressure is measured by ______and what should it be?

Answer 12

CPP and should be between 50 and 60 torr.

Question 13

CA: Cerebral perfusion monitoring including

Answer 13

EEG, Stump pressure, SSEP, TCD, and cerebral oximetry.

Question 14

ECG required. Meticulous monitoring –

Answer 14

already cerebral blood flow compromised as indication for this procedure. Measure BP in both arms. If BP is different in each arm, monitoring must be done interop and postop with cuff placed on the extremity with the higher value.

Question 15

CA: Maintain MAP

Answer 15

90-110 during occlusion and 80-100 during closure.

Question 16

CA: Vasopressors may be used interoperative to maintain

Answer 16

BP or to increase BP during occlusion.

Question 17

CA: Surgery should not occur in pt with uncontrolled

Answer 17

HTN, DM, or recent MI.

Question 18

CA: RESP smoking cessation minimum of

Answer 18

night prior to sx to increase O2 carrying capacity by decreasing carbon monoxide levels. Decreased FRC due to positioning and pressure on the diaphragm.

Question 19

CA: Cerebral insufficiency is due to either

Answer 19

critical stenosis or occlusion of cerebral vessels combined with in
adequate collateral circulation. Plaques or mural thrombi readily break off from the vessel wall and cause focal
ischemic lesions.

Question 20

Carotid sinus reflex may activate a Hyperextension and

Answer 20

decrease in BP.

Question 21

CA: Lateral rotation of head may

Answer 21

occlude vertebral-basilar flow and if sustained contributes to postop cerebral ischemia.

Question 22

CA if CBF is compromised, symptoms of dizziness or diplopia will emerge. Testing the effect of the surgical position on CBP by

Answer 22

placing the patient’s head in the operative position preoperative is desirable.

Question 23

CA: Padding elbows to prevent

Answer 23

ulnar nerve injury and occiput to prevent occipital nerve injury is important. Make sure to protect eyes.

Question 24

CA: Hematologic- ASA

Answer 24

Aspirin or antiplatelet therapy usually started preoperative to decrease the risk of thrombotic
complications. Aspirin can be continued up to the day of surgery.

Question 25

CA: Full anticoagulation

Answer 25

Full anticoagulation with Heparin (100U/kg IV) during | occlusion then reversal with Protamine 10 min after repair.

Question 26

CA: For anxiolytic

Answer 26

Midazolam 1-3mg preferable to opiates.

Question 27

CA: IV pre-incision.

Answer 27

Ancef 1-2 grams

Question 28

Pre-op/ Induction –. Induction

Answer 28

Pepcid 20mg IV and Metoclopramide 10mg IV for aspiration prophylaxis

Question 29

CA Induction -

Answer 29

100% O2 by mask x3 min. Lidocaine 1 mg/kg IV, then Propofol 1- 2mg/kg IV to keep BP at acceptable levels and decrease CMRO2. Ensure adequate mask ventilation.

Question 30

CA muscle relaxation

Answer 30

- Vecuronium 0.15 mg/kg or Rocuronium 0.6 mg/kg for muscle | relaxation.

Question 31

CA: minimize CV response to intubation.

Answer 31

Fentanyl 2-5 mcg/kg or Remifentanil 1-3 mcg/kg can

Question 32

CA Ensure

Answer 32

deep anesthesia and neuromuscular blocking then intubate. An LTA should be used to blunt reflexes.

Question 33

CA – Maintenance

Answer 33

Isoflurane up to 0.6% or Sevoflurane up to 1% with N2O 50% and Remifentanil 0.05-0.2 mcg/kg min should not interfere with EEG of EP/MEP monitoring.

Question 34

CA Maintenance when

Answer 34

When cross clamped the brain needs 100% FiO2 thus NO2 must be turned off. Additional Propofol 0.5-1 mg/kg before cross-clamping can produce burst suppression on EEG.

Question 35

CA: PONV.

Answer 35

Ondansetron 4mg IV 30 prior to case end

Question 36

CA: During the surgery if bradycardia or ectopy occurs from manipulation of the carotid bulb,

Answer 36

Notify the surgeon immediately. During surgery maintain BP 10-20% above baseline to maintain collateral circulation. BP should be slightly decreased prior to clamping to prevent spike in BP.

Question 37

Emergency Note _________on anesthetic record...

Answer 37

occlusion time

Question 38

CA: protamine

Answer 38

Protamine 0.5mg/100U Heparin (slowly) 10 minutes after | bleeding controlled.

Question 39

CA should be ready as HTN

Answer 39

B-blocker (Labetolol or Esmolol with SNP/NTG should be ready as HTN is likely upon emergence.

Question 40

CA: Iso and N2O should be

Answer 40

d/c’d and O2 flow increased to 100%. NMB reversal with Neostigmine 0.05-0.07 mg/kg IV + Glycopyrrolate 0.01 mg/kg IV

Question 41

CA: Attempt to extubate deep as

Answer 41

coughing/bucking can cause too much pressure on the surgical site. Lidocaine 4% LTA to blunt airway reflexes. O2 per NC

Question 42

Continue to monitor likely to ICU. Suction oropharynx.

Answer 42

Extubate after protective airway reflexes have returned, the patient is breathing spontaneously, and with intact neurological status (follow commands, smile is symmetrical, equal grip strength). O2 per NC. Continue to monitor cardiovascular and neurological status, likely in ICU.