Fast-Track Protocol for Carotid Surgery

Background/Objectives: Fast-track (FT) protocols have been developed to reduce the surgical burden and enhance recovery, but they still need to be established for carotid endarterectomy (CEA). In this scenario, carotid stenting has gained momentum by answering the need for a less invasive treatment, despite a still debated clinical advantage. We aim to propose a FT protocol for CEA, along with the analysis of its clinical impact. Methods: This retrospective, monocentric study enrolled consecutive patients who underwent CEA for asymptomatic carotid stenosis using a FT protocol between January 2016 and December 2024. Patients undergoing CEA for symptomatic carotid stenosis, carotid bypass procedures, and combined interventions were excluded. Our FT protocol comprises same-day hospital admission, exclusive use of local anesthesia, non-invasive assessment of cardiac and neurological status, and selective utilization of cervical drainage. Discharge criteria were goal-directed and included the absence of pain, electrocardiographic abnormalities, hemodynamic instability, neck hematoma, or cranial nerve injury, with a structured plan for rapid readmission if required.Postoperative pain was assessed using the Numerical Rating Scale (NRS), administered to all patients. The perioperative clinical impact of the protocol was evaluated based on complication rates, pain control, length of hospital stay, and early readmission rates. Results: Among 1051 patients who underwent CEA, 853 met the inclusion criteria. General anesthesia was required in 17 cases (2%), while a cervical drain was placed in 83 patients (10%). The eversion technique was employed in 765 cases (90%). Postoperative intensive care unit (ICU) monitoring was necessary for 7 patients (1%). The mean length of hospital stay was 1.17 days.Postoperatively, 17 patients (2%) required surgical revision. Minor stroke occurred in 3 patients (0.4%), and acute myocardial infarction requiring angioplasty in 2 patients (0.2%). Inadequate postoperative pain control (NRS >4) was reported by 5 patients (0.6%). Hospital readmission was required for one patient due to a neck hematoma. Conclusions: Our fast-track protocol for elective carotid surgery, designed to mitigate operative stress, demonstrated effectiveness in optimizing the quality of care, yielding significantly favorable outcomes in patients' clinical courses.