Carotid Endarterectomy Operative Note

Patient name: [Patient name]

MRN: [MRN]

Date of birth: [DOB]

Date of procedure: [Procedure date]

Start time: [Start time]

End time: [End time]

Location/OR: [Facility and OR number]

Primary surgeon: [Surgeon name]

Assistant(s): [Assistant names and roles]

Anesthesia type: [general / regional / local with sedation]

Anesthesia provider: [Provider name and role]

Preoperative diagnosis: [Laterality, carotid territory, symptomatic vs asymptomatic status, stenosis severity]

Postoperative diagnosis: [Diagnosis after procedure]

Procedure(s) performed: [Procedure name(s) with laterality]

Indication: [Symptom status, stenosis severity, imaging basis, urgency]

Prophylactic antibiotics: [Agent and timing relative to incision / Not given]

Intraoperative Findings

• Laterality and target vessel(s): [Right / Left] [ICA / CCA / ECA involvement]
• Plaque characteristics: [Ulcerated, calcified, thrombotic, friable, or other notable features / Not described]
• Anatomic variations: [High bifurcation, redundancy, prior surgery/radiation, other / None noted]
• Estimated stenosis severity: [Percentage range based on intraoperative assessment]

Devices and Implants

Patch material and size: [Bovine pericardial / Dacron / PTFE / Vein] [Size/dimensions] (If no patch used, state "Not used - primary closure" or "Not used - eversion technique")

Shunt type and size: [Shunt brand/type and size / Not used]

Drain type and location: [Drain type and placement site / Not placed]

Operative Narrative

Preparation and exposure: [Patient positioning and head turn, skin prep, incision location relative to SCM, layered dissection, identification of CCA/ICA/ECA, management of hypoglossal nerve/vagus/ansa cervicalis]

Neuromonitoring and clamp tolerance: [Monitoring modality: awake neuro exam / EEG / SSEP / stump pressure / NIRS / none]. [Baseline status prior to clamping]. [Response to ICA clamping: unchanged / changes observed]. (If changes observed, describe findings and corrective actions. Do not infer; document only what was observed.)

Anticoagulation: [Heparin dose in units and timing relative to clamping]. [ACT values if monitored / ACT not monitored].

Arterial clamping: [Clamp sequence]. [Total clamp time in minutes].

Shunt decision: Shunt [used / not used]. (If used: document indication, shunt type/size, insertion technique, and any shunt-related issues. If not used: document rationale such as stable monitoring, acceptable stump pressure, or intact awake exam.)

Endarterectomy technique: [Arteriotomy location and extent, technique (conventional vs eversion), plane of dissection and plaque removal, distal endpoint management, tacking sutures if placed, flushing and de-airing sequence].

Closure method: [Patch angioplasty / Primary closure / Eversion closure]. (If patch: include material, size, and suture type. If primary closure: note vessel size adequacy if documented.)

Protamine decision: Protamine [given / not given]. (If given: include dose and timing. If not given: document rationale such as surgeon preference, concern for thrombosis, or allergy.)

Completion imaging: [Duplex / Angiography / Not performed]. (If performed: document findings including flow pattern, residual stenosis, intimal flap, thrombus, and whether revision was required. If not performed: document alternative assessment method used.)

Hemostasis and closure: [Hemostasis technique, topical hemostatics if used, drain placement if applicable, layered closure method, dressing applied].

Specimens, EBL, and Complications

Specimen disposition: [Carotid plaque to pathology / Discarded]

Counts: [Sponge, needle, and instrument counts correct / Not documented]

Estimated blood loss: [EBL in mL]

Fluids/transfusion: [Crystalloid/colloid volumes, blood products if given / None]

Intraoperative complications: [None / Description with intraoperative management]

Disposition: [Extubated in OR / Remained intubated]; transferred to [PACU / ICU / Stepdown]

Postoperative Plan

• Immediate neurologic status: [Exam upon emergence: speech, strength, command-following / Pending at transfer] (Document explicitly; do not infer)
• Monitoring location: [PACU / ICU / Stepdown] (Include rationale if nonstandard)
• Neuro check frequency: [Cadence, e.g., q1h x 6h then q2h x 6h]
• Blood pressure goals: [Target SBP range] with hyperperfusion precautions
• Antithrombotic plan: [Antiplatelet agent(s) and resumption timing, statin continuation]
• Airway surveillance: [Instructions for escalation if neck hematoma, stridor, or airway compromise develops]
• Follow-up imaging: [Timing of postoperative carotid duplex per local practice]