Emergency management of postoperative airway obstruction following carotid endarterectomy: a systematic review.

Postoperative airway obstruction after carotid endarterectomy presents a significant challenge to anaesthetists. Airway oedema, with or without haematoma, may rapidly develop with life-threatening consequences. This systematic review aims to inform best practice in the management of postoperative airway obstruction following carotid endarterectomy. A literature search was conducted for manuscripts published between 01/01/2000 and 01/07/2025. Articles describing the anaesthetic management of adult patients who developed postoperative airway obstruction following carotid endarterectomy were included. Reference lists of the reviewed articles were also scrutinised for additional relevant sources. Outcome measures were the presentation of airway obstruction, success rate of airway interventions, duration of tracheal intubation and incidence of airway-related morbidity and mortality. Risk of bias was assessed using the Newcastle-Ottawa Scale. The literature search yielded 284 articles, of which 32 full papers were reviewed. Six papers were deemed pertinent, in addition to five identified from review of references, for a total of 11 included in this systematic review (five case reports, three case series and three retrospective observational studies) detailing the management of airway compromise post-carotid endarterectomy in 84 cases. Clinical signs correlate poorly with anatomical distortion, and laryngeal oedema is generally more severe than anticipated. Prompt haematoma evacuation improved the success rate of airway management, without associated morbidity or mortality. Surgical exploration under local anaesthesia was efficacious and may avoid the need for airway intervention. Awake tracheal intubation was associated with fewer complications than asleep tracheal intubation and should be considered where time and patient cooperation allow. Emergency front-of-neck access should not be delayed for repeated attempts at tracheal intubation with a high chance of failure. Patients' tracheas should remain intubated for sufficient time after surgical exploration, allowing airway oedema to resolve prior to extubation.