Case study: Carotid endarterectomy - NYSORA | NYSORA

Case study: Carotid endarterectomy

October 17, 2023

Case presentation

A 67-year-old male patient was diagnosed with severe stenosis of the right internal carotid artery. The patient was scheduled for carotid endarterectomy to remove the atherosclerotic plaque. Due to his age and history of stroke, it was decided to perform the surgery under regional anesthesia to allow for neurological monitoring during the procedure.

Nerve block technique

The patient was placed in a supine position with the neck slightly extended and rotated away from the side to be blocked. Next, a high-frequency linear ultrasound transducer was positioned to visualize the cervical plexus along the posterior border of the sternocleidomastoid muscle. Under ultrasound guidance, a 22-gauge, 50 mm needle was inserted using an in-plane approach. After negative aspiration and confirming correct needle placement, 10 mL of 0.25% bupivacaine was injected incrementally around the cervical plexus, while monitoring for signs of intravascular or intrathecal injection.

Reverse Ultrasound Anatomy for a cervical plexus block with needle insertion in-plane. The local anesthetic spread is shown in blue. GaN, greater auricular nerve; SCM, sternocleidomastoid muscle; LCa, longus capitis muscle, LCo, longus colli muscle; MSM, middle scalene muscle; LsCa, longissimus capitis muscle; LS, levator scapulae muscle; SPL, splenius capitis muscle; SECM, semispinalis capitis muscle. 

Patient outcome

The carotid endarterectomy was successfully completed under the cervical plexus block, with the patient remaining awake and responsive throughout the surgery. No neurological changes were noted during the clamping of the carotid artery, supporting the benefit of neurological monitoring made possible by regional anesthesia. Postoperative pain was well-managed, and no complications were observed.

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