Carotid endarterectomy (carotid artery)
This surgery is performed to remove the build-up of fatty deposits (plaque) in the carotid artery in your neck, which carries blood to your brain. If the flow of blood is reduced by plaque it can lead to a stroke or a mini-stroke (a transient ischaemic attack or TIA). Carotid endarterectomies can be performed using either a general anesthetic or a local anesthetic.
Your anesthetist will be able to explain more about the advantages and disadvantages of a local or general anesthetic. They will agree with you and your surgeon about which option is better for your surgery based on the condition of your carotid artery, your medical assessment, and your preferences.
With a local anesthetic, you will be awake during the procedure. This has the advantage that the healthcare team can talk to you and ask you to do simple tasks during the procedure, such as squeezing a hand or wriggling your toes. This way they can instantly know whether there are any problems with blood flowing to your head and neck.
An ultrasound machine is used to guide the injection of local anesthetic into your neck to numb the nerves that supply the area. You may also be offered light sedation to help you relax during the procedure. The surgery normally lasts between one and a half and three hours.
It is normal to feel some pressure once the procedure starts, but, if you feel discomfort during the surgery, you should tell your surgeon and they can give you extra local anesthetic.
Rarely, some patients may need to be offered a general anesthetic in addition to local anaesthetic. In this case, the operation will be stopped temporarily to give the general anaesthetic. With a general anaesthetic the anaesthetist may check the flow of blood to your head with a special monitor.
Recovery after a carotid endarterectomy
After carotid surgery you will usually go to either the recovery area or an HDU so that you can be carefully monitored for a few hours. When the anaesthetist and surgeon are happy that your blood pressure is stable, and that you have recovered from the anaesthetic and are feeling comfortable, you will be able to go to the ward.
Aortic aneurysm repair surgery (aorta)
An abdominal aortic aneurysm (AAA) is a bulge or swelling in the aorta, the main blood vessel that runs from the heart down through your abdomen (tummy) and to your legs. It can get bigger over time, which can lead it to burst and cause life-threatening internal bleeding.
There are two main types of surgery for an abdominal aortic aneurysm:
■ Open aortic aneurysm repair (open AAA): the abdomen is cut and the damaged aorta is replaced with an artificial tube graft.
■ Endovascular aortic aneurysm repair (EVAR): this is a keyhole operation where a stent (a short wire-mesh tube) is passed through an artery in your groin to strengthen the lining of your aorta.
There are benefits and risks with both types of surgery. These will be discussed with you, taking into account the severity of your arterial damage and your preoperative assessment test results.
Open AAA repair
A general anaesthetic is always needed for an open AAA. You will require extra monitoring such as an arterial line and possibly a central venous catheter (see ‘Equipment and monitoring used during vascular surgery’). For pain relief you may be offered an epidural or wound catheters.
Afterward, you will usually go to the ICU or the HDU. Here, your nurse and medical team will make sure that you have enough fluids, your heart, lungs, and kidneys are working well and you are comfortable. If all is well, you will usually go back to the surgical ward after one or two days.
EVAR
If your EVAR surgery is thought to be technically straightforward, it is likely to be done under local anesthetic, which will be injected into the skin in your groin to numb the area where the stents will be inserted. Sometimes other regional anesthetic techniques (spinals and epidurals) can be used (rcoa.ac.uk/patientinfo/leaflets-video-resources). You will be required to lie flat for one to two hours. You will be awake and may be offered sedation to help you relax.
If your EVAR surgery is thought to be complex or prolonged, you may require a general anesthetic. In certain cases, you may require a spinal drain.
Most patients who have had a standard EVAR procedure normally recover in the surgical ward. Patients who have had a more complex EVAR procedure may be looked after in the HDU or ICU immediately after the operation.
Artery bypass surgery in your legs (femoral artery)
This type of surgery is used to improve the flow of blood through the arteries of the legs in patients suffering from peripheral arterial disease (PAD). This is known as ‘revascularisation’.
There are two main types of revascularisation treatment for PAD:
■ Angioplasty: where a blocked or narrowed part of the artery is widened by inflating a tiny balloon placed inside it.
■ Artery bypass graft: where a blocked artery is bypassed using either one of your own blood vessels (usually a vein) or an artificial graft.
Your anesthetic for vascular surgery
These procedures can be carried out using either a general anesthetic or a regional anesthetic technique (spinal or epidural) – see the link for more information: rcoa.ac.uk/patientinfo/leaflets-video-resources
A local anesthetic may also be injected to numb the nerves supplying parts of your leg.
This is known as a nerve block.
This provides good pain relief for up to 12 hours and can reduce the amount of stronger painkillers that you require after the operation. Which technique is best for you will be decided after discussions among yourself, your anesthetist, and your surgeon, taking into consideration your medical history and fitness.
Lower limb operations can take a long time and you may need to lie flat on your back for several hours. If you are unable to lie flat for long, then a general anesthetic may be the better option. If a regional technique is used, then sedation can be used to help you relax during the procedure.
After surgery, you will go to a special recovery area where you can be closely monitored. The nurses will be checking that the blood is flowing well to the feet and legs. You will then go back to a surgical ward unless you require extra monitoring, in which case you may go to an HDU.
Pain relief after surgery
Some people need more pain relief than others or respond differently to pain-relieving drugs. Occasionally, pain is a warning sign that all is not well, so you should tell the staff to look after you if your pain increases.
Your anesthetist will discuss different options with you to help manage your pain after surgery. You will normally be given regular pain relief by mouth or into your IV line. For surgery on your aorta or blood supply to your legs, your anesthetist may also discuss with you the following options.
Continuous epidural
If you have an epidural, the epidural catheter will be left in place at the end of the operation and connected to a pump to inject anesthetic and painkillers as required after surgery. You may have some numbness over your abdomen and legs, and your limbs may feel heavier than normal until the pump is stopped. The epidural can stay in for several days after the operation.
Patient-controlled analgesia (PCA)
This is a pain relief pump connected to your cannula, which you control yourself by pressing a button. The pump has safety settings to stop you from accidentally getting too much medication.
Wound catheters
Local anesthetic is injected into your wound along one or more small plastic tubes to numb the area of the surgery. The surgeon or anesthetist will place the tubes during the operation. Wound catheters can stay in for several days after your operation.
Nerve blocks
Local anesthetic is injected around nerves that supply parts of the surgical site. An ultrasound machine is used to locate the nerves and ensure that the local anesthetic is injected safely. This may be done when you are awake or asleep depending on the surgery.
Risk and shared decision-making
Modern anesthetics are very safe. There are some common side effects from the anesthetic drugs or the equipment used, which are usually not serious or long-lasting. Risks will vary between individuals and will depend on the procedure and anesthetic technique used.
There are some specific risks associated with anesthetics for vascular surgery, including bleeding, infection, and damage to the heart and kidneys.
Your anesthetist will discuss with you the risks that they believe to be more significant for you and how these can be reduced. They will only discuss less common risks if they are relevant to you.