Anesthetic Management for Combined Carotid Endarterectomy and Coronary Artery Bypass Grafting

Two female patients were scheduled for simultaneous carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG). Anesthesia was induced with fentanyl and ketamine and maintained with nitrous oxide in oxygen plus fentanyl under EEG and full cardiac monitoring. The carotid portions of the operations were performed first to avert reduction in cerebral blood flow during extracorporeal circulation. The carotid arteries were clamped using temporary shunts and mean arterial pressure was maintained in the upper end of their preoperative range throughout the procedure. On one of the patients, abrupt circulatory disturbances (bradycardia, hypotension and PVC) took place during decollement in the right cervical region, which suggested carotid sinus syndrome. Therefore, other surgical fields adjacent to carotid sinuses were administered 1% mepivacaine to prevent carotid sinus reflex. EEG monitoring showed no abnormal finding including circulatory disturbance during each anesthetic course. In anesthetic management for combined CEA/CABG, it is necessary to prevent occurrence of carotid sinus reflex in order to maintain both cerebral and myocardial blood flow, and careful brain monitoring is essential to detect cerebral ischemia or hypoperfusion.