Variation in Anesthetic Techniques for Carotid Endarterectomy

Surgical Rounds®, March 2014,

A majority of anesthesiologists report using intraoperative neuroprotection for carotid endarterectomy, compared to a previous study that reported 22% of anesthesiologists used neuroprotection in 1995.

Carotid endarterectomy (CEA) is a surgical procedure that reduces the risk of atherosclerotic stroke by removing plaque buildup in the carotid arteries. According to the National Institutes of Health (NIH), CEA is highly beneficial for patients who have either had a stroke or experienced stroke symptoms and have a severe stenosis.

In this group, surgery reduces the estimated 2-year risk of stroke or death by more than 80%. Without CEA, 1 in 4 patients will experience an atherosclerotic stroke, while after CEA, less than 1 in 10 will.

Data from 1995 reported that anesthetic techniques varied significantly among practitioners, and little research has addressed the relationship between anesthesia type and perioperative stroke risk. To fill this knowledge gap, researchers from the Seattle, WA, area distributed an online survey to members of the Society of Cardiovascular Anesthesiologists (SCA) and Society of Neuroscience, Anesthesiology, and Critical Care (SNACC) and published the results in the Journal of Cardiothoracic and Vascular Anesthesia.

The 664 anesthesiologists who responded to the survey were employed at academic medical centers and community-based hospitals providing perioperative care for CEA. The majority of respondents indicated they received subspecialty training in cardiovascular anesthesiology (66%), had more than 10 years of experience (68%), and practiced in the United States (81%).

Although the anesthesiologists’ preferences widely varied, three-quarters of respondents preferred general anesthesia for CEA. Traditionally, electroencephalogram (EEG) for intraoperative neuromonitoring was preferred, which reflected a change in practice over the last 20 years.

A full 68% of the anesthesiologists reported using neuroprotection, compared to the previous study that reported 22% of anesthesiologists used neuroprotection and preferred barbiturates in 1995. Today, pure oxygen and increase in blood pressure have displaced barbiturates.

In terms of extubation, 59% of respondents preferred to have the patient awake, while 15% preferred deep extubation.

Among the respondents, neuroanesthesiologists and those practicing outside the US were more likely to risk-stratify patients for perioperative cerebral hyperperfusion syndrome — a rare complication that can result in hemorrhagic stroke and death.

Anesthesiologists appeared to be in agreement about several areas of perioperative management of CEA. However, some significantly divergent practice remains in the areas of perioperative blood pressure management, risk stratification for cerebral hyperperfusion syndrome, and intraoperative neuromonitoring, which the authors said presents an opportunity for anesthesiologists to work together and develop best practices guidelines.