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Abstract
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Background and Aims Carotid endarterectomy is the mainstay of treatment for symptomatic carotid artery stenosis. Perioperative management of such patients is challenging(1). Anesthetic management involves decreasing diastolic time and thus regurgitant volume, as well as reducing afterload and aortic- ventricular gradient. We report a successful case of a patient with severe aortic insufficiency who underwent carotid endarterectomy under locoregional anesthesia.
Ultrasound guided intermediate cervical plexus nerve block
Carotid endarterectomy. The image shows open, cross-clamped carotid artery
Methods A 73-year-old man, ASA IV, with severe aortic insufficiency waiting for cardiac surgery, complained of episodic amaurosis fugax. Carotid doppler ultrasound demonstrated >90% stenosis of the right internal carotid artery. Carotid endarterectomy was proposed. On preoperative study, the echocardiogram showed severe aortic insufficiency with preserved global biventricular systolic function. After informed consent and anesthetic monitoring, 1 mg of midazolam and 50 micrograms of fentanyl were administered before the anesthetic blockade. An ultrasound-guided intermediate cervical plexus block with 15 ml of 0,75% ropivacaine was performed (figure 1). Another bolus of midazolam and fentanyl were readministered within 30 minutes of the first administration and again near the end of surgery. The patient remained hemodynamically stable and the procedure (figure 2) was uneventful. After surgery, the patient was transferred to a level 2 intensive care unit.
Conclusions For carotid endarterectomy some studies describe better intraoperative hemodynamic stability as well as enhanced control of postoperative pain using a locoregional technique (2). In our case, the execution of an intermediate cervical plexus block allowed for real-time intra-operative neurological monitoring in an awake patient and less cardiovascular impact on a high-risk cardiac patient while giving optimal anaesthetic effect for surgical purposes.