Vascular Surgery

Question 1

What degree of carotid artery stenosis would indicate carotid endarterectomy?

Answer 1

> 70%

This is based on recommendations following the North American Symptomatic Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST)

Question 2

When should carotid endarterectomy occur?

Answer 2

Within 2 weeks of initial TIA symptoms

Question 3

What are the advantages and disadvantages of performing carotid endarterectomy under regional anaesthesia?

Answer 3

Advantages

- Allows neurological monitoring
- Avoids risks of general anaesthesia Better blood pressure stability throughout the procedure
- Better blood pressure stability throughout the procedure
- Reduced shunt rate
- Reduced hospital stay
- Allows arterial closure at normal arterial pressure, may reduce risk of post operative haematoma

Disadvantages

- There are risks associated with siting a regional block
- Patient may not tolerate procedure
- Stressed patient may have myocardial ischaemia
- Risk of airway loss during procedure
- Risk of local anaesthetic toxicity

Question 4

What are the regional anaesthesia options for carotid endarterectomy?

Answer 4

• Superficial cervical plexus block
• Deep cervical plexus block
• Local anaesthetic infiltration
• Cervical epidural

Cervical epidural has very serious potential complications and is rarely performed in the UK

Question 5

Explain the steps to performing a superficial cervical plexus block

Answer 5

Preparation
- AAGBI monitoring
- Awake arterial line on contralateral side
- Intravenous access on contralateral side
- Reuscitation equipment and trained assistant
- Stop before you block

Block
- Landmark technique
- Superficial injection along posterior border of sternocleidomastoid
- 10-15ml of 0.5% levobupivacaine
- Injection to submandiular region as branches may be missed by block

Question 6

What would explain a post op BP of 200/100, confusion, headache and hemiparesis after an endarterectomy, and how would you manage it?

Answer 6

• Cerebral hyperperfusion syndrome (CHS)
  
  • Ipsilateral loss of cerebral autoregulation leading to increased blood flow
  • Treatment is rapid and aggressive blood pressure control
  • 1-3% of carotid endarterectomy patients
  • Can lead to seizures and cerebral oedema