arterial blood pressure reexly. The carotid body, which lies behind the point of division of the CCA, is a small brownish red structure which acts as a chemoreceptor.

At the level of second cervical vertebral body, the vagus nerve gives its superior laryngeal nerve branch which descends along the side of the pharynx rst posterior and then medial to the ICA and divides into the internal and external laryngeal nerve.

The preference of cervical block anesthesia (CBA) over general anesthesia (GA) during performance of CEA has been debated vigorously during the past few decades. Recent results from GALA trial have not shown any superiority in the outcome following CEA for either CBA or GA.We prefer CBA except in patients with a high plaque (cephalad end of the plaque) at the level of second cervical ver­tebrae, those with anxiety disorder, patients with hearing loss, or patients with poor command of English language for whom general anesthesia is preferred.

Vertical incisions leave an unsightly scar, and transverse incisions may limit the exposure in the event the plaque extends for a considerable distance superiorly or inferiorly. The length of incision is determined by the level of carotid bifurcation in relation to the cervical vertebrae, and the extent of the plaque in the ICA and the CCA are determined by preoperative CT angiography. After dividing the platysma, the external jugular vein is ligated and divided. In the upper portion of the incision, the greater auricular nerve is preserved and mobilized posteriorly and superiorly. Division of the greater auricular nerve will result in temporary sensory loss in the corresponding lobule of the ear and angle of the jaw. Dissection plan is continued along the anteromedial border of the sternocleidomastoid muscle. A self-retaining Wheitlaner retractor is applied superiorly and one inferiorly. The dissection plane is developed among the medial border of the IJV and is continued cephalad. Common facial vein is encountered, and ligated and divided, and upper deep cervical lymph nodes are mobilized posteriorly. As the carotid sheath is opened, vagus nerve is visualized posterolaterally between the artery and the vein. Vagus nerve may descend anteriorly as it courses inferiorly. External carotid artery is looped with a silastic loop which is then pulled caudally and held with a hemostat on the drapes at the chest wall. Ansa cervicalis is seen in the upper part of the dissection and is mobi­lized anteriorly. In the exposed area above the conuence of the common facial vein to the IJV, small unnamed veins joining the IJV are ligated and divided followed by division of the sternocleidomastoid branch of the occipital artery, and this helps to mobilize the hypoglossal nerve cephalad. Local anesthetic (1% lidocaine) is inl­trated around the carotid body to prevent bradycardia. Intravenous heparin (100units/kgm) is administered by the anesthesia team monitoring of ACT.

1. Routine use of shunt

2. Selective use of shunt

3. Carotid endarterectomy without shunt

Surgeons using routine indwelling shunt generally perform the procedure under GA and do not need measurement of stump pressure and EEG monitoring to assess cerebral perfusion, but the ow through the shunt should be documented by the arte­rial Doppler. The disadvantage of routine use of the shunt is that it may interfere

Under CBA, continuous neurological assessment can be performed by having the patient squeeze with his contralateral hand with a toy that makes a “squeaky noise.” If patient develops contralateral weakness or becomes unresponsive on clamping of the CCA, a shunt is immediately placed. Carotid endarterectomy with­out shunt has been proposed by a minority of authors and has shown satisfactory results in small series.