Peri-operative Monitoring of an Asystolic Cardiac Arrest Requiring Cardiopulmonary Resuscitation During Carotid Endarterectomy for Symptomatic Carotid Artery Stenosis

Abstract Introduction A carotid endarterectomy (CEA) upholds certain risk, of which the peri-operative cardiovascular risk is one. Peri-operative neurological monitoring can be done with electroencephalography (EEG) and transcranial Doppler (TCD). No previous reports have been published demonstrating the actual changes in cerebral and cardiac activity during a peri-operative asystole. Report The case of a 70-year-old man with a symptomatic (bilateral) carotid stenosis is described. The patient complained of amaurosis fugax in both eyes. Duplex ultrasound showed a stenosis of > 70% in both carotid arteries. The most severe symptoms were on the right side, so a staged approach was decided upon, starting with a right-sided eversion CEA (eCEA). Peri-operatively, the patient experienced an asystolic cardiac arrest after external carotid artery revascularisation, requiring short cardiopulmonary resuscitation, which was recorded on the EEG. Postoperatively, the patient recovered fully, with no postoperative neurological or cardiac sequelae. The (symptomatic) contralateral stenosis was treated conservatively with best medical therapy (BMT; dual antiplatelets and statin). The patient is currently in good clinical condition, 1.5 years later. Conclusion This case shows the unique EEG recording of a cardiologic event during eCEA. The cause of this asystole was most likely a vasovagal syncope as a result of the surgical procedure by iatrogenic damage of the carotid sinus fibres, causing impairment of the baroreflex and chemoreflex mechanisms, which is higher during eCEA. The unilateral eCEA and contralateral BMT in this symptomatic (bilateral) stenosis seemed appropriate when cardiologic risk was increased, but follow up ruled out any cardiologic cause.