The patient was scheduled in the morning hours for elective carotid endarterectomy. The attending surgeon explained to the patient that he will perform conventional endarterectomy and patch plasty. The procedure was performed under general anesthesia using motor and somatosensory evoked potential monitoring.
According to the largest existing RCT and latest ESVS Guidelines on the management of carotid artery disease there are no difference between regional and general anesthesia when performing carotid endarterectomy.
Source: Gough MJ; GALA Trial Collaborators. The GALA Trial–a summary of the findings. Eur J Vasc Endovasc Surg. 2008 Nov;36(5):505-6. doi: 10.1016/j.ejvs.2008.09.001.
Source: Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, et al. Editor’s Choice – European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg. 2023 Jan;65(1):7-111. doi: 10.1016/j.ejvs.2022.04.011.
Further details about the use of the use of motor and somatosensory evoked potentials can be found in the following video:
The only neuromonitoring method during carotid cross clamping that provides an ideal surveilance of cerebral perfusion is an awake test. However, compared to awake test there is lack of high quality data to propose the use of one specific cerebral perfusion monitoring over another (electroencephalography [EEG], stump pressure, backflow, TCD, transcranial cerebral oximetry, near infrared spectroscopy), as the following paper shows. Also, the latest ESVS guidelines do not provide recommendations about the optimal neuromonitoring method.
Source: Jovanovic A, Jonsson M, Roy J, Eriksson J, Mutavdzic P, Trailovic R, et al. Comparison of Methods for Monitoring Intra-operative Cerebral Perfusion in Patients Undergoing Carotid Endarterectomy with Selective Shunting: A Systematic Review and Network Meta-Analysis of Randomised Controlled Trials and Cohort Studies. 2023; 65(2): 233-243.
Source: Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, et al. Editor’s Choice – European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg. 2023 Jan;65(1):7-111. doi: 10.1016/j.ejvs.2022.04.011.
