Anesthetic management of carotid endarterectomy: an update from Italian guidelines

Both general anaesthesia (GA) and regional anaesthesia (RA) may be used to conduct carotid endarterectomy (CEA). Cooperative patient general anaesthesia (CPGA) has been added to the two previously described conventional anaesthetic modalities in recent years. It has never been proved that one anaesthetic modality is superior than another, particularly in terms of postoperative complications such as stroke, myocardial infarction, and mortality.

The perioperative stroke is one of the most scary consequences of CEA . Continuous intraoperative neurological monitoring is often recommended to prevent neurological problems caused by carotid clamping-induced restriction of cerebral blood flow. Currently, both clinical and instrumental brain monitoring are used, although none has been associated with a superior result.

The Italian recommendations for the diagnosis and treatment of extracranial carotid stenosis and prevention of cerebral stroke were released on the website of the Italian Institute of Health . The primary objective is to examine the most recent research regarding anaesthetic, intraoperative neurologic monitoring, postoperative heparin reversal, and postoperative blood pressure control in carotid endarterectomies.

Recommendation 1: In patients having carotid endarterectomy, the free selection of regional anaesthesia, general anaesthesia, or cooperative patient general anaesthesia is advised, based on the center's expertise, the patient's desire, and clinical state.

Strong LOE for 1+++

Recommendation 2: For patients undergoing carotid endarterectomy, it is suggested that additional, preferably multicenter studies be conducted to determine the preferences and relative levels of patient satisfaction regarding the type of anaesthesia administered: regional anaesthesia, general anaesthesia, or cooperative patient general anaesthesia.

Recommendation 3. In carotid endarterectomy patients, clinical or instrumental cerebral intraoperative monitoring be selected according to the kind of anaesthetic and the temporary shunting approach. Clinical monitoring is nonetheless more sensitive.

Strong LOE for 2+

Recommendation 4: Patients having carotid endarterectomy should be monitored using many instrumental methods, since the combination of techniques may enhance the sensitivity compared to a single technique.

Recommendation 5: For patients undergoing carotid endarterectomy, additional studies, preferably multicenter, are recommended to determine whether intraoperative heparin reversal with protamine at the end of surgery could reduce bleeding complications without increasing the risk of thrombosis in the postoperative period.

Recommendation 6: In patients having carotid endarterectomy, postoperative blood pressure monitoring and the subsequent therapy of arterial hypertension are recommended, as contrasted to no postoperative blood pressure monitoring.

After carotid endarterectomy, any technique of anaesthetic and neurological monitoring is associated with a better result, according to this most recent data. In addition, there was inadequate data to warrant reversing or not reversing heparin at the conclusion of operation. Moreover, despite the lack of data, a recommendation for postoperative blood pressure monitoring was made.

Reference –

Bevilacqua, S., Ticozzelli, G., Orso, M. et al. Anesthetic management of carotid endarterectomy: an update from Italian guidelines. J Anesth Analg Crit Care 2, 24 (2022). https://doi.org/10.1186/s44158-022-00052-9