Carotid endarterectomy: GA versus awake and cerebral monitoring

Meet the patient

A 72-year-old smoker with a symptomatic 80 percent left internal carotid stenosis and a recent TIA presents for carotid endarterectomy. He takes aspirin and a beta-blocker, his baseline BP is 150 over 90, and he can lie flat and hold a conversation. The surgeon asks: awake or asleep?^[1]

The two questions that decide his outcome are the two every CEA turns on: can I monitor his brain during the clamp? and can I defend his blood pressure through clamp and reperfusion? Get those right and the technique choice almost does not matter — GALA proved that.^[1]

References5ShowHide

1. [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. [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. [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. [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. [5]Moulakakis KG, Mylonas SN, Sfyroeras GS, et al. Hyperperfusion syndrome after carotid revascularization. J Vasc Surg, 2009.PMID 19249185