Carotid Endarterectomy using Regional Anesthesia: Technique and Considerations.

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Varun Padmanaban, Catherine Caldwell, Indigo Milne, Sprague W. Hazard, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3025356/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Jun, 2024 Read the published version in Frontiers in Surgery → Version 1 posted You are reading this latest preprint version Abstract BACKGROUND Carotid endarterectomy (CEA) is one of the most effective neurosurgical operations in minimizing stroke risk in both symptomatic and asymptomatic patients with carotid stenosis. Awake CEA with regional anesthesia may decrease both perioperative complications and length of hospital stay. The awake carotid operation is not often described in published literature. OBJECTIVE To describe our experience with carotid endarterectomy using regional anesthesia with a focus on patient selection, anatomic variations, and surgical technique including cervical regional block. We particularly focus on nuances of the awake approach. METHODS Carotid endarterectomy using regional anesthesia is described in detail. RESULTS Successful use of regional anesthesia during carotid endarterectomy without complication. CONCLUSION Regional anesthesia for CEA is an advantageous approach for cervical plaque removal in appropriate patients. Thoughtful patient selection, as well as understanding of anatomy and its variants, is required. Potential advantages and disadvantages are discussed. Awake carotid endarterectomy regional anesthesia cervical block Figures Figure 1 Figure 2 Figure 3 Introduction Stroke is among the leading causes of death and accounts for a large portion of healthcare costs in the United States and globally[ 1 ]. Roughly 10% of ischemic cerebral infarctions are due to extracranial atherosclerotic cerebrovascular disease[ 2 ]. Removal of atherosclerotic plaque causing stenosis of internal carotid arteries through carotid endarterectomy (CEA) is arguably the most effective operation in minimizing stroke risk in both symptomatic and asymptomatic patients with carotid stenosis, with a number needed to treat of approximately 6 and 19 respectively[ 3 , 4 ]. Carotid endarterectomy may be performed under either regional or general anesthesia. Regional anesthesia allows for at least equivalent results in patients who are unable to tolerate general anesthesia[ 5 – 7 ] and may be associated with shorter hospital length of stay, reduced anesthesia and operative time, decreased complications including pneumonia and cranial nerve injury, and lower costs[ 8 – 15 ]. In this technical paper we review the importance of patient selection, anatomical variations, and operative nuances including cervical block for performing CEA under regional anesthesia. Appropriate informed consent was obtained for surgical photos. Review of Anatomy A nuanced understanding of the cervical plexus and its variations is essential to performing carotid endarterectomy under regional anesthesia. Sensation to the skin and superficial structures of the anterolateral neck is supplied by the superficial or cutaneous cervical plexus. It has origins from the ventral rami of nerve roots C2 to C4. These branches exit at the midpoint along the posterior border of the sternocleidomastoid muscle, superficial to the prevertebral fascia at approximately the level of the thyroid cartilage posterior to the external jugular vein. These roots form four major terminal branches: The lesser occipital (C2), greater auricular (C2-3), transverse cervical (C2-3) and supraclavicular nerves (C3-4). The deep or muscular cervical plexus innervates the deeper structures of the neck, including muscles of anterior neck and diaphragm via the ansa cervicalis, phrenic and segmental branches. The carotid artery itself, including the carotid bulb, is innervated by the carotid branch of the glossopharyngeal nerve, eponymously named Hering’s nerve. One may encounter many anatomic variations during surgery, and an appropriate preoperative assessment including various imaging modalities should be used to prepare for the individual patient. A poor initial response to cervical block may indicate variations within sensory branches of the cervical plexus. These should be kept in mind when performing the block. Operative Technique Preoperative Workup . Patient selection in awake CEA is similar to CEA with general anesthesia including symptomatic carotid artery disease with 70–99% stenosis. Asymptomatic patients and those with moderate stenosis may be selected on a case-by-case basis. Those who have suffered a large, debilitating stroke may benefit from delayed CEA. In patients who suffered a transient ischemic attack or mild to moderate stroke, urgency may be warranted given the increased risk of stroke in the first weeks after the initial event. Preoperative evaluation should include a careful history and physical examination, as well as preoperative imaging. Patients with language or cognitive deficits may not tolerate regional anesthesia. History of previous neck surgery may warrant evaluation of the recurrent laryngeal nerve. Discussing peri- and postoperative expectations regarding regional anesthesia is of paramount importance. The procedure must be done expeditiously but may still cause significant anxiety and physical discomfort. While the senior authors performs most CEAs awake with cervical block, some patients are too anxious to benefit from this approach. We collaborate with our patients to decide together on regional versus general anesthesia, and we find most patients strongly prefer the awake approach citing a fear of general anesthesia and an interest in participating in the surgery to ensure the best possible outcome. Table 1 reviews relative contraindications to performing awake versus asleep CEA. Table 1 Relative contraindications to performing asleep versus awake CEA Awake CEA Asleep CEA • Morbid obesity • Obstructive sleep apnea • Severe back/neck pain • Claustrophobic patients • Surgeon discomfort • Neurological deficit precluding intra-operative exam • Non-English speaker • High anesthesia risk • Hemodynamic instability Preoperative Planning . Under regional anesthesia, maximizing comfort for the patient while in the operating room is key to the success of the operation. We generally refrain from using central and arterial lines, urinary catheter, and sequential compression devices unless their use is imperative to the performance of a safe procedure. Minimizing anxiety of the patient is requisite for the success of CEA under local anesthesia. We encourage conversing with the patient throughout the operation, and music may be played to the patient’s preference. Keeping the atmosphere of the operative room calm and light ensures favorable operative conditions for the surgeon and an improved patient experience. The attending surgeon may need to take time at the beginning of the case and even pause throughout the case to create and maintain this atmosphere. Operation . The patient is positioned supine with the head facing away from the side of the affected vessel. A large, folded pillow is placed under the patient’s neck to achieve adequate extension and elevation without compromising patient comfort. An elevated gel donut supports the patient’s head. Draping between surgeon and anesthesiologist is kept at waist level and drapes are kept away from the patient’s face in order to maximize communication and minimize anxiety (Fig. 1 ). An insufflated oblong device with an audible pressure release valve (aka squeaky toy) is taped to the patients hand contralateral to the affected carotid. This is used for neurological testing during the operation (Fig. 2 ). Blood pressure is generally maintained at the patient’s baseline, and may be elevated 10% during internal carotid artery (ICA) clamping on a case-by-case basis. A forced air patient warming system may be utilized to help regulate the patient’s temperature during the case and promote normothermia. The surgeon or the anesthesiologist may perform the cervical field block. Regional anesthesia is achieved with a superficial cervical block utilizing 0.5% lidocaine. Maximum dosage (approximately 4.5 mg/kg) should be noted to avoid potential systemic toxicity. To obtain adequate blockage, a generous volume is injected along one third to two thirds of the posterior aspect of the sternocleidomastoid muscle fanning superiorly and inferiorly (star, Fig. 3 ). Ultrasound may be utilized to visualize the cervical plexus, although the plexus is not always easily visible, and ultrasound is not necessary in most cases. In our experience, maximizing the overall volume of lidocaine is more important than concentration, therefore we dilute our 0.5% lidocaine 1:1 in normal saline (to form 0.25% lidocaine). Minimal sedation should be involved to prevent patient confusion and ensure accurate neurological monitoring. However, low basal drips of dexmedetomidine and remifentanil may be helpful for highly anxious patients. It should be noted that dexmedetomidine may cause blood pressure and heart rate changes, while remifentanil may cause respiratory depression. A transverse incision may be beneficial for cosmetic outcome and is placed 2 finger breadths below the mandible from 1 cm off midline to 1 cm behind the angle of the mandible. The incision is tucked in a dominant skin crease if possible. A vertical incision along the mesial border of the sternocleidomastoid muscle may also be used, particularly in the case of high carotid bifurcation or when shunting is anticipated. In the senior authors’ experience, there are very few bifurcations that cannot be readily reached with a vertical incision that curves slightly posterior at its superior extent. Local anesthetic should be injected along the incision line, particularly at the cephalad aspect where the cervical block may not be as effective. The opening is performed in the standard fashion along the anterior border of the sternocleidomastoid muscle, mesial to the jugular vein, to the carotid sheath. The vagus nerve runs between the jugular vein and the common carotid artery (CCA) and is carefully protected. Working cephalad, the common facial vein may be ligated and cut. At this point the medial retractor blade must stay superficial to prevent injury to the recurrent laryngeal nerve. The hypoglossal nerve is commonly found beneath or adjacent to the posterior belly of the diagastric muscle and must be carefully protected. While the diagastric may be retracted superiorly with a hook, the nerve must be treated with care. There is commonly a contribution from the hypoglossal to the vagus. Cutting this allows further exposure of the ICA to the skull base if necessary. We typically maintain patients on dual antiplatelet medications and also administer heparin at 100 U/kg prior to dissection of the ICA. Patients often complain of a deep visceral pain during this portion of the dissection which can be treated with a small dose of lidocaine injected into the carotid sheath at the bulb. A very small IV dose of a short acting opioid can also be utilized. After optimizing blood pressure, clamps and clips are placed in the standard fashion beginning with the ICA and ending with the external carotid artery (ECA). Throughout the clamp time the patient should be tested for motor function by squeezing the toy and, when operating on the dominant side, speech function through conversation. It is essential to be prepared for a smooth transition to shunt should there be changes in the neurological exam. In the awake setting, this can lead to stress for the patient and the team, and a well-planned and even rehearsed shunt placement will keep all at ease. Two loops of umbilical tape are placed around the CCM and a single loop is placed around the ICA, allowing for the Rummel clamp should a shunt be required. A long silk tie should be secured around the shunt to keep it from moving within the vessel out of the reach. The senior authors prefers to use an Argyle shunt and place the shunt in the distal ICA first. After the Rummel is advanced, the shunt can be backbled before placing it in the CCA. This approach minimizes blood loss, keeps the field clear, and keeps the team and the patient calm. To remove the shunt, two snaps are placed through the remaining arteriotomy, and the shunt is cut between the clamps. The two ends are removed sequentially as the vessels are again clamped for the final closure. The endarterectomy is performed in the standard fashion. We cut the plaque sharply in the CCA, extricate it from the ECA and feather the endarterectomy in the ICA. If the plaque does not feather nicely in the ICA, it can be tacked to the endothelium with double arm prolene stitches. After back bleeding the ICA, the arteriotomy is closed in the standard fashion. We use a patch on an as needed basis. It is common to rush the closure in an awake patient, and this temptation must be resisted. To obtain hemostasis, half the heparin dose is reversed with protamine at 10 minutes post clamping. Meticulous coagulation and application of hemostatic materials is paramount. The sternocleidomastoid muscle and platysma are re-approximated to close open spaces where hematoma may form. Discussion Key Results. Carotid endarterectomy with regional anesthesia was pioneered by neurosurgeons such as R. E Harbaugh and has continued as a highly effective approach to the CEA operation[ 8 – 11 ]. A prospective randomized study as well as subgroup analysis of the CREST trial comparing the two techniques reported that the combined rates of cerebral infarction, myocardial infarction, and perioperative death were similar for local/regional anesthesia versus general anesthesia, while local/regional anesthesia resulted in better outcomes for patients who had occlusion of the contralateral internal carotid artery[ 5 , 6 ]. A recent Cochrane meta-analysis has also shown equivalence between the two methods[ 16 ]. Multiple, smaller studies have shown that regional anesthesia is associated with decreased rates of complications, shorter hospital stays, and lower costs compared to general anesthesia[ 7 – 15 ]. Without neurological monitoring of an awake patient, surgeons must employ either routine use of shunts for all patients undergoing CEA or neurological monitoring via electroencephalogram, transcranial Doppler scanning, and determinations of ICA back pressure. Routine use of shunt placement may lead to a higher rate of postoperative stroke/transient ischemic attack[ 17 , 18 ]. Experience with regional anesthesia can help to extend the population that can undergo CEA due to chronic disease that might make general anesthesia risky, including advanced inoperable coronary artery disease, and chronic obstructive pulmonary disease[ 11 ]. A common fear in both patients and their surgeons considering regional anesthesia for CEA is agitation during surgery. In our experience, limiting intravenous anesthetic to keep the patient truly awake and ensuring patient comfort is essential. Pausing, stopping and reassessing if the patient is uncomfortable is integral, especially prior to the critical components of the surgery. In truly critical situations, an oral airway and intravenous sedation with dexmedetomidine or remifentanil maybe utilized. An expeditious operation is also integral to ensuring the patient can tolerate the entire procedure. A few patients may not tolerate awake surgery well due to personality features and personal preference. A candid preoperative discussion with realistic expectations is essential. While we strongly prefer the awake approach and recommend this to most patients, some patients are not well suited for regional anesthesia and may do better with general anesthesia with neurophysiological monitoring. Conclusion Regional anesthesia for CEA is an advantageous approach for cervical plaque removal in appropriate patients due to its association with fewer complications, shorter hospital stays, and lower costs. A strong patient-physician team, in addition to thoughtful considerations to maximize patient comfort, are critical to allow for minimized anxiety throughout the operation. Good patient selection, mastery of normal and abnormal anatomy, thorough cervical block, and comfort with complication management and technical nuances as detailed above will yield excellent outcomes in awake CEA. Declarations Ethical approval Informed consent including consent to publish were obtained for images utilized in the preparation of this manuscript. Competing interests The authors have no relevant financial or non-financial interests to disclose. Author Contributions All authors contributed to the study conception and design. Material preparation was performed by Varun Padmanaban, Catherine Caldwell and Indigo Milne. The first draft of the manuscript was written by Varun Padmanaban with editing and technical expertise provided by Sprague Hazard, Robert Harbaugh and Ephraim Church. All authors read and approve the final manuscript. Funding The authors declare that no funds, grants or other support were received during the preparation of this manuscript. Availability of data and materials Not applicable for this manuscript. References Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol 2021; 20 :795–820. doi:10.1016/S1474-4422(21)00252-0 Flaherty ML, Kissela B, Khoury JC, et al. Carotid artery stenosis as a cause of stroke. Neuroepidemiology 2013; 40 :36–41. doi:10.1159/000341410 Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA 1995; 273 :1421–8. Ferguson GG, Eliasziw M, Barr HW, et al. The North American Symptomatic Carotid Endarterectomy Trial : surgical results in 1415 patients. Stroke 1999; 30 :1751–8. doi:10.1161/01.str.30.9.1751 Lewis SC, Warlow CP, Bodenham AR, et al. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet (London, England) 2008; 372 :2132–42. doi:10.1016/S0140-6736(08)61699-2 Hye RJ, Voeks JH, Malas MB, et al. Anesthetic type and risk of myocardial infarction after carotid endarterectomy in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). J Vasc Surg 2016; 64 :3-8.e1. doi:10.1016/j.jvs.2016.01.047 Lumas S, Hsiang W, Akhtar S, et al. Regional Anesthesia is Underutilized for Carotid Endarterectomy Despite Improved Perioperative Outcomes Compared with General Anesthesia. Ann Vasc Surg 2021; 73 :336–43. doi:10.1016/j.avsg.2020.11.035 Harbaugh RE, Patel A. Surgical advances for extracranial carotid stenosis. Neurosurgery 2014; 74 Suppl 1 :S83-91. doi:10.1227/NEU.0000000000000150 Papavasiliou AK, Magnadottir HB, Gonda T, et al. Clinical outcomes after carotid endarterectomy: comparison of the use of regional and general anesthetics. J Neurosurg 2000; 92 :291–6. doi:10.3171/jns.2000.92.2.0291 Magnadottir HB, Lightdale N, Harbaugh RE. Clinical outcomes for patients at high risk who underwent carotid endarterectomy with regional anesthesia. Neurosurgery 1999; 45 :782–6. doi:10.1097/00006123-199910000-00011 Harbaugh RE, Magnadottir HB. Carotid endarterectomy in high risk patients. Neurol Res 2002; 24 Suppl 1 :S66-70. doi:10.1179/016164102101199936 Harbaugh KS, Harbaugh RE. Early discharge after carotid endarterectomy. Neurosurgery 1995; 37 :215–9. doi:10.1227/00006123-199508000-00005 Gomes M, Soares MO, Dumville JC, et al. Cost-effectiveness analysis of general anaesthesia versus local anaesthesia for carotid surgery (GALA Trial). Br J Surg 2010; 97 :1218–25. doi:10.1002/bjs.7110 Grieff AN, Dombrovskiy V, Beckerman W, et al. Anesthesia Type is Associated with Decreased Cranial Nerve Injury in Carotid Endarterectomy. Ann Vasc Surg 2021; 70 :318–25. doi:10.1016/j.avsg.2019.12.033 Malik OS, Brovman EY, Urman RD. The Use of Regional or Local Anesthesia for Carotid Endarterectomies May Reduce Blood Loss and Pulmonary Complications. J Cardiothorac Vasc Anesth 2019; 33 :935–42. doi:10.1053/j.jvca.2018.08.195 Rerkasem A, Orrapin S, Howard DP, et al. Local versus general anaesthesia for carotid endarterectomy. Cochrane database Syst Rev 2021; 10 :CD000126. doi:10.1002/14651858.CD000126.pub5 Bennett KM, Scarborough JE, Cox MW, et al. The impact of intraoperative shunting on early neurologic outcomes after carotid endarterectomy. J Vasc Surg 2015; 61 :96–102. doi:10.1016/j.jvs.2014.06.105 Wisman PP, Nolthenius RPT, Tromp SC, et al. Longer time interval between carotid cross-clamping and shunting is associated with increased 30-day stroke and death rate. Vasc Endovascular Surg 2011; 45 :335–9. doi:10.1177/1538574411403168 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 05 Jun, 2024 Read the published version in Frontiers in Surgery → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3025356","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Method Article","associatedPublications":[],"authors":[{"id":207525919,"identity":"e53faa09-aa12-4dfa-a670-3e233a67a427","order_by":0,"name":"Varun Padmanaban","email":"","orcid":"","institution":"Pennsylvania State University, Penn State Milton S. Hershey Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Varun","middleName":"","lastName":"Padmanaban","suffix":""},{"id":207525920,"identity":"5cac150d-2a28-4daa-8018-19e67c58b67c","order_by":1,"name":"Catherine Caldwell","email":"","orcid":"","institution":"Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Catherine","middleName":"","lastName":"Caldwell","suffix":""},{"id":207525923,"identity":"563ae97e-c35a-4e93-8270-92796e185622","order_by":2,"name":"Indigo Milne","email":"","orcid":"","institution":"Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Indigo","middleName":"","lastName":"Milne","suffix":""},{"id":207525924,"identity":"3f114acf-0660-48d3-9551-d9ce8746cf76","order_by":3,"name":"Sprague W. Hazard","email":"","orcid":"","institution":"Pennsylvania State University, Penn State Milton S. Hershey Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Sprague","middleName":"W.","lastName":"Hazard","suffix":""},{"id":207525925,"identity":"7db04f38-a63c-4959-999a-44d748de5244","order_by":4,"name":"Robert E. Harbaugh","email":"","orcid":"","institution":"Pennsylvania State University, Penn State Milton S. Hershey Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Robert","middleName":"E.","lastName":"Harbaugh","suffix":""},{"id":207525926,"identity":"22d6d5fb-efd4-4157-b48c-4b943528282b","order_by":5,"name":"Ephraim W. Church","email":"data:image/png;base64,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","orcid":"","institution":"Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Ephraim","middleName":"W.","lastName":"Church","suffix":""}],"badges":[],"createdAt":"2023-06-05 15:29:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3025356/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3025356/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.3389/fsurg.2024.1421624","type":"published","date":"2024-06-06T00:33:51+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":38242471,"identity":"4d63e7ff-2d2d-442c-8e36-7551f229b3c4","added_by":"auto","created_at":"2023-06-08 16:24:17","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1135772,"visible":true,"origin":"","legend":"\u003cp\u003eAppropriate positioning and draping for a patient undergoing awake carotid endarterectomy. Note positioning of surgical towels \u003cstrong\u003e(A)\u003c/strong\u003eand drapes \u003cstrong\u003e(B)\u003c/strong\u003e.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-3025356/v1/813395370e47beafb65f6aaa.png"},{"id":38242473,"identity":"6d145d1d-9f8e-414d-8668-19fae88bdc06","added_by":"auto","created_at":"2023-06-08 16:24:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":619358,"visible":true,"origin":"","legend":"\u003cp\u003eSample of auditory device taped to patient’s hand contralateral to affected carotid artery.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-3025356/v1/5788061abda888be08b6a2b6.png"},{"id":38242472,"identity":"196164eb-49ac-456c-8887-82b1354800ea","added_by":"auto","created_at":"2023-06-08 16:24:17","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":943946,"visible":true,"origin":"","legend":"\u003cp\u003eAppropriate starting point of cervical block (star) approximately one third to two thirds along the posterior border of the sternocleidomastoid (line).\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-3025356/v1/9174e478872c4aeae4510592.png"},{"id":58160651,"identity":"a3c08137-d16b-47b3-9fb3-102923b481a5","added_by":"auto","created_at":"2024-06-12 00:33:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5095554,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3025356/v1/84afef93-6cd1-4275-9330-e8ac495ddcda.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Carotid Endarterectomy using Regional Anesthesia: Technique and Considerations.","fulltext":[{"header":"Introduction","content":"\u003cp\u003eStroke is among the leading causes of death and accounts for a large portion of healthcare costs in the United States and globally[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Roughly 10% of ischemic cerebral infarctions are due to extracranial atherosclerotic cerebrovascular disease[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Removal of atherosclerotic plaque causing stenosis of internal carotid arteries through carotid endarterectomy (CEA) is arguably the most effective operation in minimizing stroke risk in both symptomatic and asymptomatic patients with carotid stenosis, with a number needed to treat of approximately 6 and 19 respectively[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCarotid endarterectomy may be performed under either regional or general anesthesia. Regional anesthesia allows for at least equivalent results in patients who are unable to tolerate general anesthesia[\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] and may be associated with shorter hospital length of stay, reduced anesthesia and operative time, decreased complications including pneumonia and cranial nerve injury, and lower costs[\u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12 CR13 CR14\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In this technical paper we review the importance of patient selection, anatomical variations, and operative nuances including cervical block for performing CEA under regional anesthesia. Appropriate informed consent was obtained for surgical photos.\u003c/p\u003e\n\u003ch3\u003eReview of Anatomy\u003c/h3\u003e\n\u003cp\u003eA nuanced understanding of the cervical plexus and its variations is essential to performing carotid endarterectomy under regional anesthesia. Sensation to the skin and superficial structures of the anterolateral neck is supplied by the superficial or cutaneous cervical plexus. It has origins from the ventral rami of nerve roots C2 to C4. These branches exit at the midpoint along the posterior border of the sternocleidomastoid muscle, superficial to the prevertebral fascia at approximately the level of the thyroid cartilage posterior to the external jugular vein. These roots form four major terminal branches: The lesser occipital (C2), greater auricular (C2-3), transverse cervical (C2-3) and supraclavicular nerves (C3-4). The deep or muscular cervical plexus innervates the deeper structures of the neck, including muscles of anterior neck and diaphragm via the ansa cervicalis, phrenic and segmental branches. The carotid artery itself, including the carotid bulb, is innervated by the carotid branch of the glossopharyngeal nerve, eponymously named Hering\u0026rsquo;s nerve.\u003c/p\u003e \u003cp\u003eOne may encounter many anatomic variations during surgery, and an appropriate preoperative assessment including various imaging modalities should be used to prepare for the individual patient. A poor initial response to cervical block may indicate variations within sensory branches of the cervical plexus. These should be kept in mind when performing the block.\u003c/p\u003e"},{"header":"Operative Technique","content":"\u003cp\u003e \u003cem\u003ePreoperative Workup\u003c/em\u003e. Patient selection in awake CEA is similar to CEA with general anesthesia including symptomatic carotid artery disease with 70\u0026ndash;99% stenosis. Asymptomatic patients and those with moderate stenosis may be selected on a case-by-case basis. Those who have suffered a large, debilitating stroke may benefit from delayed CEA. In patients who suffered a transient ischemic attack or mild to moderate stroke, urgency may be warranted given the increased risk of stroke in the first weeks after the initial event. Preoperative evaluation should include a careful history and physical examination, as well as preoperative imaging. Patients with language or cognitive deficits may not tolerate regional anesthesia. History of previous neck surgery may warrant evaluation of the recurrent laryngeal nerve.\u003c/p\u003e \u003cp\u003eDiscussing peri- and postoperative expectations regarding regional anesthesia is of paramount importance. The procedure must be done expeditiously but may still cause significant anxiety and physical discomfort. While the senior authors performs most CEAs awake with cervical block, some patients are too anxious to benefit from this approach. We collaborate with our patients to decide together on regional versus general anesthesia, and we find most patients strongly prefer the awake approach citing a fear of general anesthesia and an interest in participating in the surgery to ensure the best possible outcome. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e reviews relative contraindications to performing awake versus asleep CEA.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRelative contraindications to performing asleep versus awake CEA\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAwake CEA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAsleep CEA\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Morbid obesity\u003c/p\u003e \u003cp\u003e\u0026bull; Obstructive sleep apnea\u003c/p\u003e \u003cp\u003e\u0026bull; Severe back/neck pain\u003c/p\u003e \u003cp\u003e\u0026bull; Claustrophobic patients\u003c/p\u003e \u003cp\u003e\u0026bull; Surgeon discomfort\u003c/p\u003e \u003cp\u003e\u0026bull; Neurological deficit precluding intra-operative exam\u003c/p\u003e \u003cp\u003e\u0026bull; Non-English speaker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; High anesthesia risk\u003c/p\u003e \u003cp\u003e\u0026bull; Hemodynamic instability\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003ePreoperative Planning\u003c/em\u003e. Under regional anesthesia, maximizing comfort for the patient while in the operating room is key to the success of the operation. We generally refrain from using central and arterial lines, urinary catheter, and sequential compression devices unless their use is imperative to the performance of a safe procedure. Minimizing anxiety of the patient is requisite for the success of CEA under local anesthesia. We encourage conversing with the patient throughout the operation, and music may be played to the patient\u0026rsquo;s preference. Keeping the atmosphere of the operative room calm and light ensures favorable operative conditions for the surgeon and an improved patient experience. The attending surgeon may need to take time at the beginning of the case and even pause throughout the case to create and maintain this atmosphere.\u003c/p\u003e \u003cp\u003e \u003cem\u003eOperation\u003c/em\u003e. The patient is positioned supine with the head facing away from the side of the affected vessel. A large, folded pillow is placed under the patient\u0026rsquo;s neck to achieve adequate extension and elevation without compromising patient comfort. An elevated gel donut supports the patient\u0026rsquo;s head. Draping between surgeon and anesthesiologist is kept at waist level and drapes are kept away from the patient\u0026rsquo;s face in order to maximize communication and minimize anxiety (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). An insufflated oblong device with an audible pressure release valve (aka squeaky toy) is taped to the patients hand contralateral to the affected carotid. This is used for neurological testing during the operation (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Blood pressure is generally maintained at the patient\u0026rsquo;s baseline, and may be elevated 10% during internal carotid artery (ICA) clamping on a case-by-case basis. A forced air patient warming system may be utilized to help regulate the patient\u0026rsquo;s temperature during the case and promote normothermia.\u003c/p\u003e \u003cp\u003eThe surgeon or the anesthesiologist may perform the cervical field block. Regional anesthesia is achieved with a superficial cervical block utilizing 0.5% lidocaine. Maximum dosage (approximately 4.5 mg/kg) should be noted to avoid potential systemic toxicity. To obtain adequate blockage, a generous volume is injected along one third to two thirds of the posterior aspect of the sternocleidomastoid muscle fanning superiorly and inferiorly (star, Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Ultrasound may be utilized to visualize the cervical plexus, although the plexus is not always easily visible, and ultrasound is not necessary in most cases. In our experience, maximizing the overall volume of lidocaine is more important than concentration, therefore we dilute our 0.5% lidocaine 1:1 in normal saline (to form 0.25% lidocaine). Minimal sedation should be involved to prevent patient confusion and ensure accurate neurological monitoring. However, low basal drips of dexmedetomidine and remifentanil may be helpful for highly anxious patients. It should be noted that dexmedetomidine may cause blood pressure and heart rate changes, while remifentanil may cause respiratory depression.\u003c/p\u003e\u003cp\u003eA transverse incision may be beneficial for cosmetic outcome and is placed 2 finger breadths below the mandible from 1 cm off midline to 1 cm behind the angle of the mandible. The incision is tucked in a dominant skin crease if possible. A vertical incision along the mesial border of the sternocleidomastoid muscle may also be used, particularly in the case of high carotid bifurcation or when shunting is anticipated. In the senior authors\u0026rsquo; experience, there are very few bifurcations that cannot be readily reached with a vertical incision that curves slightly posterior at its superior extent. Local anesthetic should be injected along the incision line, particularly at the cephalad aspect where the cervical block may not be as effective.\u003c/p\u003e \u003cp\u003eThe opening is performed in the standard fashion along the anterior border of the sternocleidomastoid muscle, mesial to the jugular vein, to the carotid sheath. The vagus nerve runs between the jugular vein and the common carotid artery (CCA) and is carefully protected. Working cephalad, the common facial vein may be ligated and cut. At this point the medial retractor blade must stay superficial to prevent injury to the recurrent laryngeal nerve. The hypoglossal nerve is commonly found beneath or adjacent to the posterior belly of the diagastric muscle and must be carefully protected. While the diagastric may be retracted superiorly with a hook, the nerve must be treated with care. There is commonly a contribution from the hypoglossal to the vagus. Cutting this allows further exposure of the ICA to the skull base if necessary.\u003c/p\u003e \u003cp\u003eWe typically maintain patients on dual antiplatelet medications and also administer heparin at 100 U/kg prior to dissection of the ICA. Patients often complain of a deep visceral pain during this portion of the dissection which can be treated with a small dose of lidocaine injected into the carotid sheath at the bulb. A very small IV dose of a short acting opioid can also be utilized. After optimizing blood pressure, clamps and clips are placed in the standard fashion beginning with the ICA and ending with the external carotid artery (ECA). Throughout the clamp time the patient should be tested for motor function by squeezing the toy and, when operating on the dominant side, speech function through conversation.\u003c/p\u003e \u003cp\u003eIt is essential to be prepared for a smooth transition to shunt should there be changes in the neurological exam. In the awake setting, this can lead to stress for the patient and the team, and a well-planned and even rehearsed shunt placement will keep all at ease. Two loops of umbilical tape are placed around the CCM and a single loop is placed around the ICA, allowing for the Rummel clamp should a shunt be required. A long silk tie should be secured around the shunt to keep it from moving within the vessel out of the reach. The senior authors prefers to use an Argyle shunt and place the shunt in the distal ICA first. After the Rummel is advanced, the shunt can be backbled before placing it in the CCA. This approach minimizes blood loss, keeps the field clear, and keeps the team and the patient calm. To remove the shunt, two snaps are placed through the remaining arteriotomy, and the shunt is cut between the clamps. The two ends are removed sequentially as the vessels are again clamped for the final closure.\u003c/p\u003e \u003cp\u003eThe endarterectomy is performed in the standard fashion. We cut the plaque sharply in the CCA, extricate it from the ECA and feather the endarterectomy in the ICA. If the plaque does not feather nicely in the ICA, it can be tacked to the endothelium with double arm prolene stitches. After back bleeding the ICA, the arteriotomy is closed in the standard fashion. We use a patch on an as needed basis.\u003c/p\u003e \u003cp\u003eIt is common to rush the closure in an awake patient, and this temptation must be resisted. To obtain hemostasis, half the heparin dose is reversed with protamine at 10 minutes post clamping. Meticulous coagulation and application of hemostatic materials is paramount. The sternocleidomastoid muscle and platysma are re-approximated to close open spaces where hematoma may form.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e \u003cem\u003eKey Results.\u003c/em\u003e Carotid endarterectomy with regional anesthesia was pioneered by neurosurgeons such as R. E Harbaugh and has continued as a highly effective approach to the CEA operation[\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. A prospective randomized study as well as subgroup analysis of the CREST trial comparing the two techniques reported that the combined rates of cerebral infarction, myocardial infarction, and perioperative death were similar for local/regional anesthesia versus general anesthesia, while local/regional anesthesia resulted in better outcomes for patients who had occlusion of the contralateral internal carotid artery[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. A recent Cochrane meta-analysis has also shown equivalence between the two methods[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Multiple, smaller studies have shown that regional anesthesia is associated with decreased rates of complications, shorter hospital stays, and lower costs compared to general anesthesia[\u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11 CR12 CR13 CR14\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWithout neurological monitoring of an awake patient, surgeons must employ either routine use of shunts for all patients undergoing CEA or neurological monitoring via electroencephalogram, transcranial Doppler scanning, and determinations of ICA back pressure. Routine use of shunt placement may lead to a higher rate of postoperative stroke/transient ischemic attack[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Experience with regional anesthesia can help to extend the population that can undergo CEA due to chronic disease that might make general anesthesia risky, including advanced inoperable coronary artery disease, and chronic obstructive pulmonary disease[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA common fear in both patients and their surgeons considering regional anesthesia for CEA is agitation during surgery. In our experience, limiting intravenous anesthetic to keep the patient truly awake and ensuring patient comfort is essential. Pausing, stopping and reassessing if the patient is uncomfortable is integral, especially prior to the critical components of the surgery. In truly critical situations, an oral airway and intravenous sedation with dexmedetomidine or remifentanil maybe utilized. An expeditious operation is also integral to ensuring the patient can tolerate the entire procedure.\u003c/p\u003e \u003cp\u003eA few patients may not tolerate awake surgery well due to personality features and personal preference. A candid preoperative discussion with realistic expectations is essential. While we strongly prefer the awake approach and recommend this to most patients, some patients are not well suited for regional anesthesia and may do better with general anesthesia with neurophysiological monitoring.\u003c/p\u003e "},{"header":"Conclusion","content":"\u003cp\u003eRegional anesthesia for CEA is an advantageous approach for cervical plaque removal in appropriate patients due to its association with fewer complications, shorter hospital stays, and lower costs. A strong patient-physician team, in addition to thoughtful considerations to maximize patient comfort, are critical to allow for minimized anxiety throughout the operation. Good patient selection, mastery of normal and abnormal anatomy, thorough cervical block, and comfort with complication management and technical nuances as detailed above will yield excellent outcomes in awake CEA.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent including consent to publish were obtained for images utilized in the preparation of this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation was performed by Varun Padmanaban, Catherine Caldwell and Indigo Milne. The first draft of the manuscript was written by Varun Padmanaban with editing and technical expertise provided by Sprague Hazard, Robert Harbaugh and Ephraim Church. All authors read and approve the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable for this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGlobal, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. \u003cem\u003eLancet Neurol\u003c/em\u003e 2021;\u003cstrong\u003e20\u003c/strong\u003e:795\u0026ndash;820. doi:10.1016/S1474-4422(21)00252-0\u003c/li\u003e\n\u003cli\u003eFlaherty ML, Kissela B, Khoury JC, \u003cem\u003eet al.\u003c/em\u003e Carotid artery stenosis as a cause of stroke. \u003cem\u003eNeuroepidemiology\u003c/em\u003e 2013;\u003cstrong\u003e40\u003c/strong\u003e:36\u0026ndash;41. doi:10.1159/000341410\u003c/li\u003e\n\u003cli\u003eEndarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. \u003cem\u003eJAMA\u003c/em\u003e 1995;\u003cstrong\u003e273\u003c/strong\u003e:1421\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eFerguson GG, Eliasziw M, Barr HW, \u003cem\u003eet al.\u003c/em\u003e The North American Symptomatic Carotid Endarterectomy Trial : surgical results in 1415 patients. \u003cem\u003eStroke\u003c/em\u003e 1999;\u003cstrong\u003e30\u003c/strong\u003e:1751\u0026ndash;8. doi:10.1161/01.str.30.9.1751\u003c/li\u003e\n\u003cli\u003eLewis SC, Warlow CP, Bodenham AR, \u003cem\u003eet al.\u003c/em\u003e General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. \u003cem\u003eLancet (London, England)\u003c/em\u003e 2008;\u003cstrong\u003e372\u003c/strong\u003e:2132\u0026ndash;42. doi:10.1016/S0140-6736(08)61699-2\u003c/li\u003e\n\u003cli\u003eHye RJ, Voeks JH, Malas MB, \u003cem\u003eet al.\u003c/em\u003e Anesthetic type and risk of myocardial infarction after carotid endarterectomy in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). \u003cem\u003eJ Vasc Surg\u003c/em\u003e 2016;\u003cstrong\u003e64\u003c/strong\u003e:3-8.e1. doi:10.1016/j.jvs.2016.01.047\u003c/li\u003e\n\u003cli\u003eLumas S, Hsiang W, Akhtar S, \u003cem\u003eet al.\u003c/em\u003e Regional Anesthesia is Underutilized for Carotid Endarterectomy Despite Improved Perioperative Outcomes Compared with General Anesthesia. \u003cem\u003eAnn Vasc Surg\u003c/em\u003e 2021;\u003cstrong\u003e73\u003c/strong\u003e:336\u0026ndash;43. doi:10.1016/j.avsg.2020.11.035\u003c/li\u003e\n\u003cli\u003eHarbaugh RE, Patel A. Surgical advances for extracranial carotid stenosis. \u003cem\u003eNeurosurgery\u003c/em\u003e 2014;\u003cstrong\u003e74 Suppl 1\u003c/strong\u003e:S83-91. doi:10.1227/NEU.0000000000000150\u003c/li\u003e\n\u003cli\u003ePapavasiliou AK, Magnadottir HB, Gonda T, \u003cem\u003eet al.\u003c/em\u003e Clinical outcomes after carotid endarterectomy: comparison of the use of regional and general anesthetics. \u003cem\u003eJ Neurosurg\u003c/em\u003e 2000;\u003cstrong\u003e92\u003c/strong\u003e:291\u0026ndash;6. doi:10.3171/jns.2000.92.2.0291\u003c/li\u003e\n\u003cli\u003eMagnadottir HB, Lightdale N, Harbaugh RE. Clinical outcomes for patients at high risk who underwent carotid endarterectomy with regional anesthesia. \u003cem\u003eNeurosurgery\u003c/em\u003e 1999;\u003cstrong\u003e45\u003c/strong\u003e:782\u0026ndash;6. doi:10.1097/00006123-199910000-00011\u003c/li\u003e\n\u003cli\u003eHarbaugh RE, Magnadottir HB. Carotid endarterectomy in high risk patients. \u003cem\u003eNeurol Res\u003c/em\u003e 2002;\u003cstrong\u003e24 Suppl 1\u003c/strong\u003e:S66-70. doi:10.1179/016164102101199936\u003c/li\u003e\n\u003cli\u003eHarbaugh KS, Harbaugh RE. Early discharge after carotid endarterectomy. \u003cem\u003eNeurosurgery\u003c/em\u003e 1995;\u003cstrong\u003e37\u003c/strong\u003e:215\u0026ndash;9. doi:10.1227/00006123-199508000-00005\u003c/li\u003e\n\u003cli\u003eGomes M, Soares MO, Dumville JC, \u003cem\u003eet al.\u003c/em\u003e Cost-effectiveness analysis of general anaesthesia versus local anaesthesia for carotid surgery (GALA Trial). \u003cem\u003eBr J Surg\u003c/em\u003e 2010;\u003cstrong\u003e97\u003c/strong\u003e:1218\u0026ndash;25. doi:10.1002/bjs.7110\u003c/li\u003e\n\u003cli\u003eGrieff AN, Dombrovskiy V, Beckerman W, \u003cem\u003eet al.\u003c/em\u003e Anesthesia Type is Associated with Decreased Cranial Nerve Injury in Carotid Endarterectomy. \u003cem\u003eAnn Vasc Surg\u003c/em\u003e 2021;\u003cstrong\u003e70\u003c/strong\u003e:318\u0026ndash;25. doi:10.1016/j.avsg.2019.12.033\u003c/li\u003e\n\u003cli\u003eMalik OS, Brovman EY, Urman RD. The Use of Regional or Local Anesthesia for Carotid Endarterectomies May Reduce Blood Loss and Pulmonary Complications. \u003cem\u003eJ Cardiothorac Vasc Anesth\u003c/em\u003e 2019;\u003cstrong\u003e33\u003c/strong\u003e:935\u0026ndash;42. doi:10.1053/j.jvca.2018.08.195\u003c/li\u003e\n\u003cli\u003eRerkasem A, Orrapin S, Howard DP, \u003cem\u003eet al.\u003c/em\u003e Local versus general anaesthesia for carotid endarterectomy. \u003cem\u003eCochrane database Syst Rev\u003c/em\u003e 2021;\u003cstrong\u003e10\u003c/strong\u003e:CD000126. doi:10.1002/14651858.CD000126.pub5\u003c/li\u003e\n\u003cli\u003eBennett KM, Scarborough JE, Cox MW, \u003cem\u003eet al.\u003c/em\u003e The impact of intraoperative shunting on early neurologic outcomes after carotid endarterectomy. \u003cem\u003eJ Vasc Surg\u003c/em\u003e 2015;\u003cstrong\u003e61\u003c/strong\u003e:96\u0026ndash;102. doi:10.1016/j.jvs.2014.06.105\u003c/li\u003e\n\u003cli\u003eWisman PP, Nolthenius RPT, Tromp SC, \u003cem\u003eet al.\u003c/em\u003e Longer time interval between carotid cross-clamping and shunting is associated with increased 30-day stroke and death rate. \u003cem\u003eVasc Endovascular Surg\u003c/em\u003e 2011;\u003cstrong\u003e45\u003c/strong\u003e:335\u0026ndash;9. doi:10.1177/1538574411403168\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Awake carotid endarterectomy, regional anesthesia, cervical block","lastPublishedDoi":"10.21203/rs.3.rs-3025356/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3025356/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBACKGROUND\u003c/h2\u003e \u003cp\u003eCarotid endarterectomy (CEA) is one of the most effective neurosurgical operations in minimizing stroke risk in both symptomatic and asymptomatic patients with carotid stenosis. Awake CEA with regional anesthesia may decrease both perioperative complications and length of hospital stay. The awake carotid operation is not often described in published literature.\u003c/p\u003e\u003ch2\u003eOBJECTIVE\u003c/h2\u003e \u003cp\u003eTo describe our experience with carotid endarterectomy using regional anesthesia with a focus on patient selection, anatomic variations, and surgical technique including cervical regional block. We particularly focus on nuances of the awake approach.\u003c/p\u003e\u003ch2\u003eMETHODS\u003c/h2\u003e \u003cp\u003eCarotid endarterectomy using regional anesthesia is described in detail.\u003c/p\u003e\u003ch2\u003eRESULTS\u003c/h2\u003e \u003cp\u003eSuccessful use of regional anesthesia during carotid endarterectomy without complication.\u003c/p\u003e\u003ch2\u003eCONCLUSION\u003c/h2\u003e \u003cp\u003eRegional anesthesia for CEA is an advantageous approach for cervical plaque removal in appropriate patients. Thoughtful patient selection, as well as understanding of anatomy and its variants, is required. Potential advantages and disadvantages are discussed.\u003c/p\u003e","manuscriptTitle":"Carotid Endarterectomy using Regional Anesthesia: Technique and Considerations.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-06-08 16:24:12","doi":"10.21203/rs.3.rs-3025356/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f8c44f37-3393-47c1-a40c-b0da8b76072d","owner":[],"postedDate":"June 8th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-06-12T00:33:51+00:00","versionOfRecord":{"articleIdentity":"rs-3025356","link":"https://doi.org/10.3389/fsurg.2024.1421624","journal":{"identity":"frontiers-in-surgery","isVorOnly":true,"title":"Frontiers in Surgery"},"publishedOn":"2024-06-06 00:33:51","publishedOnDateReadable":"June 6th, 2024"},"versionCreatedAt":"2023-06-08 16:24:12","video":"","vorDoi":"10.3389/fsurg.2024.1421624","vorDoiUrl":"https://doi.org/10.3389/fsurg.2024.1421624","workflowStages":[]},"version":"v1","identity":"rs-3025356","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3025356","identity":"rs-3025356","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}