Anesthesia for Vascular Surgery - Carotid Revascularization
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General ConsiderationsCarotid revascularization is performed in patients with stenotic lesions of the internal carotid artery. These lesions often present as carotid bruits and may produce TIAs or strokes. The indication for surgical revascularization takes into account patient life expectancy, surgical complication rates, the presence of symptoms, and the degree of stenosis. CEA is indicated for patients with nondisabling stroke or TIA who have greater than 70% stenosis by noninvasive imaging, as long as their life expectancy is greater than or equal to 5 years and the surgeon's perioperative stroke and death risk is less than 6%. The data are less clear for patients with asymptomatic disease. CEA may be indicated in asymptomatic males with greater than 70% stenosis and a life expectancy in excess of 5 years if the surgeon's perioperative stroke and death risk is less than 3%. It is not clear that CEA is more effective than medical therapy in women with asymptomatic carotid artery stenosis. If the patient does not meet criteria for surgical revascularization, risk factor modification with medical therapy and lifestyle changes is instituted. This consists of statin and antiplatelet therapy, smoking cessation, blood pressure control, and management of diabetes. CEA is the preferred modality for operative therapy of carotid artery stenosis. The role of carotid artery stenting (CAS) is still being defined. Evidence suggests that CAS and CEA have similar long-term results, but CAS is associated with a higher rate of periprocedural morbidity and mortality. In symptomatic patients, CAS is recommended for patients with difficult surgical access (i.e., prior neck dissections) or radiation-induced carotid stenosis as long as the surgeon's postoperative stroke and death risk is less than 6%. CAS is not recommended for patients with asymptomatic carotid artery stenosis.Along with the standard history and physical, the preoperative anesthetic assessment should focus on the documentation of existing neurologic deficits as well as the range of motion of the patient's neck.