2. General Rules
1. Vascular patients require high vigilant monitoring
Options: ICU or Vascular Step Down Units.
2. Myocardial ischemia and cardiac morbidity occur
most frequently in the postoperative period.
3. Almost 90% of ischemic episodes are “silent”
4. The determinants of myocardial oxygen supply
and demand should be optimized for all patients
5. β-Blocker and statin therapy should be continued
throughout the postoperative period
4. General Rules
6. Even in the absence of coagulopathy, bleeding
through fresh vascular anastomoses may occur
when significant postoperative hypertension is
untreated.
7. Residual hypothermia in the early postoperative
period is associated with an increased incidence of
myocardial ischemia and cardiac morbidity.
5. General Rules
8. Avoid Stress response postoperatively like:
o Control Pain
o Correct Anemia
o Correct Hypothermia
o Control Haemodynamics
o Correct ventillatory insufficiency
9. When possible, extubation in the operating room is less
stressful.
10. Careful sedation and expeditious weaning are desirable
6. Complications of CEA
Remember:
CAE is 3 times as effective as medical therapy alone in reducing
incidence of stroke in patients with symptomatic stenosis of 70 – 99%
Complication rate should be maintained at an extremely low rate <3% by
surgeons to keep the beneficial effects of carotid endarterectomy over
medical therapy (Grade-A recommendation)
7. Complications of CEA
1. Wound Hematoma: (5.5%)
• Majority are relatively small causing little
discomfort
• Larger ones require evacuation
• If no loss of airway Emergency evacuation in
operating room
• If airway obstructed it is better to open
wound at bedside.
8. Complications of CEA
2. Hypertension: (73.5%)
• Poorly controlled preoperative HTN increase
risk of postop complications e.g; Hematoma and
Hyperperfusion syndrome
• Particular peak of rise is highest in the first 48hrs.
• Cause is Baroreceptor Failure Syndrome
• Associated with bilateral procedures
• This variability persists till 12 weeks
• Controlled by Hydralazine, Labetalol, GTN, B-
Blockers.
9. Complications of CEA
3. Hypotension: (5%)
• Occurs after reactivation of baroreceptor
activity and resolves in 24-48hrs
• Responds well to fluids and low dose
phenyepherine
• If persistent significant hypotension Rule out
MI via cardiac enzymes & serial EKGs
10. Complications of CEA
4. Hyperperfusion Syndrome:
• Occurs in high grade stenosis ( 90% and above)
and longstanding hypoperfusion.
• Can lead to paralysis and autoregulation failure
• Distal collaterals remain maximally dilated after
endarterectomy breakthrough pressure can
results in edema and haemorrhage
• Characterised by severe unilateral headache
improved by upright posture
11. Complications of CEA
5. Intracerebral Haemorrhage: (0.6%)
• Occurs secondary to hyperperfusion syndrome
(within 2 weeks)
• Associated with poor outcomes
• Strict control of blood pressure is mandatory
12. Complications of CEA
6. Seizures: (3%)
• Fortunately these are uncommon
• Caused by brain edema following
hyperperfusion syndrome
• Regardless of whether or not ICU care is
provided, high risk patients, such as those with
preoperative HTN, should be closely monitored for
24hrs (Grade-B recommendation)
13. Discharge
Patient should be made aware of the:
1. Significance of Unilateral Headache
2. Any new neurological symptom
3. Importance of Good BP Control
