Airway management in patients who develop neck hematomas after carotid endarterectomy

Progressive airway compromise from neck hematoma and edema is a feared complication of carotid endarterectomy (CEA). Despite this, the relationship of airway management technique to patient outcome has not been systematically studied in this population. We report the rate of successful airway management using various techniques in post-CEA patients.

A 10-year retrospective analysis was conducted to identify patients requiring airway management for neck exploration within 72 hours after CEA at Mayo Clinic, Rochester, MN.

Three thousand two hundred twenty-five patients underwent CEA over a 10-year period at our institution. Forty-four (1.4%) required neck exploration for hematoma, and 42 of these required airway management immediately before neck exploration surgery. (The tracheal tube had not been removed after CEA in the remaining 2 patients.) The average interval between the completion of CEA and return to the operating room for hematoma evacuation was 6.0 +/- 6.0 hours (mean +/- SD; range, <1-32 hours). Fiberoptic airway management, performed before the induction of anesthesia, was successful in 15 of 20 patients (75%) and, in patients in whom fiberoptic tracheal intubation failed, direct laryngoscopy (DL) was successful in all 5 (3 before and 2 after the induction of general anesthesia). In the remaining 22 patients, DL was used as the initial management technique without a trial of fiberoptic intubation. DL was successful in 5 of 7 patients (71%) when performed before induction of general anesthesia and was successful in 13 of 15 patients (87%) when performed after induction of general anesthesia. Hematoma decompression facilitated DL in 3 of 4 failures of DL; tracheostomy was performed in the remaining patient. An arterial site of bleeding was subsequently identified in 36% of patients in whom no difficulty was encountered during laryngoscopy for hematoma evacuation versus 6% in whom difficulty was noted (P = 0.03). In 36 of 44 patients (82%), the tracheal tube was removed within 24 hours of surgery for neck exploration. No adverse events related to airway management were noted. There were no deaths at 2 weeks after hematoma evacuation.

Multiple techniques resulted in successful airway control both before and after the induction of general anesthesia. Tracheal intubation was accomplished with both fiberoptic visualization and DL. In instances of poor direct visualization of the glottis, decompression of the airway by opening of the surgical incision may facilitate intubation of the trachea.