Perioperative Cerebral and Hemodynamic Monitoring in Carotid Endarterectomy

Cardiovascular diseases (CVD), such as ischemic heart disease and stroke, account for one third of all deaths from all causes globally. For the majority of CVD atherosclerosis is the underlying pathology. Atherosclerosis is a systemic lipid driven inflammatory disease of the arterial vessel wall and cause narrowing/stenosis of the vessel. Significant atherosclerotic stenosis of the carotid artery is the major cause of ischemic cerebrovascular diseases (stroke/TIA). To prevent for future stroke, carotid artery revascularization by carotid endarterectomy is the recommended treatment in patients with symptomatic carotid artery stenosis. However, the benefit of carotid artery revascularization for severe carotid artery stenosis is offset by stroke due to the intervention itself. One in three of periprocedural strokes and the majority of postoperative strokes are suggested to be of hemodynamic origin, making adequate cerebral perfusion of utmost importance. This thesis evaluated the several aspects of current clinical care (part I), procedural hemodynamic monitoring (part II), and postoperative cerebral and hemodynamic (remote) monitoring (part III) in order to optimize the current periprocedural monitoring during and following carotid endarterectomy. Studies in this thesis showed that several technical improvements have led to a decrease of stroke over the past years. However, hemodynamic and cerebral monitoring before, during and after surgery of the carotid artery are widely diverse nationwide and aim for a detailed protocol to improve standardization of care. This thesis also presented evidence that (preoperative) blood pressure has a role on atherosclerotic plaque characteristics and on the development of new (silent) ischemic brain lesions. Postoperative cerebral monitoring turned out to be effective in excluding patients at risk for cerebral hyperperfusion syndrome. Finally, postoperative blood pressure monitoring techniques were evaluated in both intramural as extra mural setting. In conclusion, studies in this thesis provide evidence that blood pressure regulation and cerebral monitoring can contribute in decreasing the complication risk that is accompanied by carotid artery surgery and have a supporting role for vascular surgeon and anaesthesiologist.