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Carotid Endarterectomy — FRCA Final MCQ

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HardGeneral AnaesthesiaCarotid EndarterectomyFRCA Final

A 60-year-old man (ASA III) is undergoing right carotid endarterectomy under regional anaesthesia with superficial and deep cervical plexus blocks. During carotid cross-clamping, his mean arterial pressure is maintained approximately 20% above his pre-clamp awake baseline; oxygenation and ventilation are normal, and no additional sedative has recently been administered. Five minutes after application of the cross-clamp, he develops persistent left-sided hemiparesis. A further brief increase in arterial pressure produces no neurological improvement. What is the most appropriate definitive action?

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Correct answer: E — Insert a temporary intraluminal carotid shunt

Persistent left hemiparesis after right carotid cross-clamping is direct awake evidence of inadequate right hemispheric perfusion. Initial reversible contributors include hypotension, hypoxaemia, abnormal ventilation and excessive sedation. Here these have been excluded, arterial pressure is already above baseline, and further augmentation has failed; a temporary intraluminal carotid shunt is therefore required to restore cerebral blood flow while the endarterectomy proceeds. Further pressor escalation may increase myocardial and bleeding risk without overcoming inadequate collateral flow. General anaesthesia removes the most reliable neurological monitor but does not restore perfusion. Additional heparin does not treat haemodynamic clamp ischaemia. Temporary declamping may reverse the deficit while preparations are made, but abandoning the operation is not the appropriate definitive strategy when shunting is feasible.

Reference: Rockman CB et al. Incidence, timing, and causes of cerebral ischemia during carotid endarterectomy with regional anesthesia. Journal of Vascular Surgery. 1998. https://pubmed.ncbi.nlm.nih.gov/11878740/