Carotid Bypass and Reconstruction Periprocedural Care

Updated: Aug 30, 2016
  • Author: Cheong Jun Lee, MD; Chief Editor: Vincent Lopez Rowe, MD  more...
  • Print
Periprocedural Care

Equipment

Equipment used for carotid bypass and reconstruction includes the following:

  • Surgical loupes (×2.5, ×3.5)
  • Fine vascular clamps and instruments (ie, a cervical carotid endarterectomy set), including detachable occluding clips (eg, Heifetz or Yasargil)
  • Short occluding balloons if the vessel is not amenable to clamping
  • Arterial shunts (eg, Javid or Sundt)
  • Polytetrafluoroethylene (PTFE) or other prosthetic grafts of appropriate length and caliber – 6-mm grafts are commonly used for the internal carotid artery (ICA) and 8-mm grafts for the common carotid artery (CCA)
  • Sternotomy set
  • Doppler ultrasonography device for intraoperative assessment of blood flow
Next:

Patient Preparation

Anesthesia

Carotid bypass and reconstruction are usually performed with general anesthesia because extensive exposure of the neck and sternotomy may be necessary. If mandibular subluxation is required for high distal targets (C1 and above), nasotracheal intubation is used. It is critical to monitor intraoperative blood pressure control and oxygenation during arterial clamping. Placement of an arterial line is thus necessary. Judicious use of vasopressors or vasodilators by the anesthesia team to maintain optimal physiologic range is of paramount importance.

Monitoring of cerebral perfusion can be accomplished by measuring ICA back-pressure before clamping or by performing intraoperative electroencephalography (EEG). The authors’ practice has been to use selective shunt placement on the basis of ICA back-pressure measurements (mean arterial pressure <40 mm Hg). In cases where the sole vessel to the brain requires clamping, high-dose propofol and burst suppression anesthesia may be useful.

Positioning

The procedure is performed with the patient supine and the neck extended. A shoulder roll is placed to assist with neck extension. The patient’s arms are tucked, and the back is raised slightly (10-20°) in a modified beach chair position, which helps reduce venous pressure. The patient’s head is turned so as to expose the side on which revascularization is required, and the endotracheal (ET) tube is positioned and taped away from that side.

If both sides require exposure (as in a carotid-to-carotid bypass), the ET tube is placed in the center and flexed away from neck. If the saphenous vein or the superficial femoral artery is required as a conduit, then the extremity from which the vessel will be procured is prepared and draped accordingly.

Previous
Next:

Monitoring and Follow-up

After the procedure, frequent neurologic assessment and maintenance of blood pressure (with appropriate treatment of hypotension or hypertension) are paramount. Drains are placed selectively for neck decompression or continued drainage of infected fluid. The operative wound is checked often. An expanding hematoma should be identified early and promptly managed in the operating room. Patients are maintained on an antiplatelet agent. Systemic anticoagulation is reserved for high-risk grafts; the risk of major bleeding is significant.

Surveillance of the reconstruction postoperatively can be effectively performed with duplex examination, as is the case after carotid endarterectomy. Significant alterations in blood flow warrant prompt imaging with computed tomographic angiography (CTA), magnetic resonance angiography (MRA), or conventional angiography to prevent graft occlusion.

Previous