Anaes SAQs · Vascular anaesthesia
Carotid endarterectomy: GA versus awake and cerebral monitoring
Final-examination SAQ for carotid-endarterectomy-anaesthesia.
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ANZCAFRCAEDAICABAFCAI
Prompt
Symptomatic carotid stenosis for CEA. Discuss GA vs awake with reference to GALA and intraoperative ischaemia management.
Model answer
GALA (5). 3,526 patients, primary composite 4.8% general vs 4.5% local (RR 0.94) — no significant difference; individualise by patient, surgeon, and monitoring strength.[1]
Monitoring (5). Awake neuro exam (taught gold standard) vs EEG/TCD/stump surrogates; shunt selectively by monitor — stump series used below 30 mmHg with no consensus, surgeon preference governs.[1][4]
BP (5). MAP at or above baseline during clamp to drive collaterals (taught); tight postoperative control against hyperperfusion (impaired autoregulation, fatal after haemorrhage); neck-haematoma airway plan with bedside opening if stridor (taught).[5]
References5ShowHide
- [1]Lewis SC, Warlow CP, Bodenham AR, et al. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet, 2008.PMID 19041130
- [2]Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation, 1999.PMID 10477528
- [3]Devereaux PJ, Yang H, Yusuf S, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet, 2008.PMID 18479744
- [4]Chia MC, Wallace GA, Cheng BT, et al. Identifying a Safe Carotid Stump Pressure Threshold for Selective Shunting During Carotid Endarterectomy. Ann Vasc Surg, 2020.PMID 32554199
- [5]Moulakakis KG, Mylonas SN, Sfyroeras GS, et al. Hyperperfusion syndrome after carotid revascularization. J Vasc Surg, 2009.PMID 19249185