79th PostGraduate Assembly in Anesthesiology 2025

Delayed Carotid Endarterectomy (CEA) Bleed and Difficult Airway

Francis Tawiah B.S., Emily Ellison M.D., Michael Morgan M.D., David Fryzel M.D., Alexander Kapral B.S., Suzanne Kozloski B.S.

1Department of Anesthesiology, Geisinger Medical Center, Danville, Pennsylvania

2Geisinger Commonwealth School of Medicine

Introduction:

Carotid endarterectomy is a common vascular procedure performed to reduce stroke risk, but postoperative neck hematoma remains a dangerous complication capable of rapidly compromising the airway. Patients with previously uncomplicated airways can experience sudden obstruction due to expanding hematoma, making early recognition and prompt intervention critical.

Case Description:

A 74-year-old male underwent right carotid endarterectomy and was awaiting discharge from PACU to the floor. During his PACU stay, the patient exhibited increased work of breathing with an expanding hematoma at the surgical site. Airway exam at this time showed Mallampati I, full neck mobility, and tracheal deviation to the left. The patient was previously intubated using direct laryngoscopy without difficulty.

Patient was brought emergently to the OR. On induction, spontaneous ventilation was maintained. Direct and video laryngoscopy revealed severe pharyngeal edema and esophageal intubation occurred with desaturation to 60%. The ETT was removed, and an LMA was placed, restoring SpO₂ to 100%. While vascular surgery reopened the wound, multiple fiberoptic attempts through the LMA failed. Discussion with vascular and trauma surgery resulted in a surgical tracheostomy, ultimately securing the airway. On POD 5, rebleeding required surgical re-exploration. The patient was stabilized and transferred to a tertiary care facility.

Discussion:

Postoperative neck hematoma occurs in approximately 1–2%of patients after carotid endarterectomy and accounts for upto 60% of airway-related complications in this setting [1].This case illustrates the life-threatening potential ofhematoma-induced airway obstruction. Despite a previouslyunremarkable airway exam and successful intubation, rapidtissue swelling and tracheal deviation led to failed direct andvideo-assisted attempts. Fiberoptic intubation via LMA alsofailed, which is consistent with a 20–30% failure rate inanatomically distorted airways [2]. Preserving spontaneousventilation during induction, in line with ASA difficultairway guidelines, proved critical. LMA placement enabledtemporary oxygenation, but definitive airway controlrequired emergent surgical tracheostomy. Rebleedingoccurred on POD 5, necessitating re-operation, acomplication seen in up to 10% of hematoma evacuations[3]. This case highlights the need for vigilant monitoring,individualized airway strategies, and early surgicalcollaboration in high-risk vascular patients.

Conclusion:

This case highlights the unpredictable andpotentially life-threatening nature ofpostoperative neck hematomas followingcarotid endarterectomy. Even patients withpreviously normal airway examinations canexperience rapid deterioration, making earlyrecognition and decisive managementessential. Maintaining spontaneous ventilation,preparing multiple backup airway strategies,and coordinating promptly with surgical teamswere key to securing the airway in this high-risk scenario. This experience reinforces theimportance of vigilance in the immediatepostoperative period and highlights howadaptable, team-based airway management canprevent catastrophic outcomes.

References:

Cohen, S. M. (2016). Postoperative hematoma: Acomplication of carotid surgery. Otolaryngologic Clinicsof North America, 49(3), 845–852.
Apfelbaum, J. L., Hagberg, C. A., Caplan, R. A., Blitt,C. D., Connis, R. T., Nickinovich, D. G., & Benumof,J. L. (2013). Practice guidelines for management of thedifficult airway. Anesthesiology, 118(2), 251–270
Argo, F., De Silva, R. P., Osman, I., & Walker, D.(2009). Management of airway obstruction due topostoperative hematoma following carotidendarterectomy. Journal of Vascular Surgery, 49(2),500–503

79th PostGraduate Assembly in Anesthesiology 2025

Delayed Carotid Endarterectomy (CEA) Bleed and Difficult Airway

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