Is general anaesthetic preffered when performing a carotid endarterectomy?

Is it preferred to have a carotid endarterectomy under general or local anaesthetic? Again, there's been a trial which talks about, which looked into that called the GALA trial, which effectively showed equivalence of both techniques. So therefore a lot of whether you undertake a carotid endarterectomy under general or local anaesthetic will depend on local practices, surgeon and anaesthetist preference. One of the advantages of a local anaesthetic carotid is the neurological monitoring in real time so you can actually get the patient to, whilst you're operating on the neck, to continue talking to you or squeezing an item them on the behest of the anaesthetist and monitor their cerebral function that way. And that's obviously reassuring to both the surgeon and the anaesthetist. The reasons for doing that are, as I described before, is you have to apply clamps onto the carotid and you temporarily stop flow to the brain through that vessel. Obviously, there are other vessels that supply the brain, namely the vertebral arteries and the carotid on the other side, that sometimes the connections at the base of the brain between all those vessels are, can be damaged as part of, you know, age or long term risk factors. And so you can have the occasion where when you apply clamps on the carotid, the patient does lose supply to a section of the brain transiently and they do stop talking or they do stop squeezing on that squeezy ball that the anaesthetist has given them and then you at least know at that time point that there's a need to place a shunt which is an artificial plastic bypass tube to continue flow through that carotid whilst you're actually doing the repair. So yeah again that depends on you know surgeon preference and the centre preference and the usual practice of the unit. There are other surgeons who, for example, do all their carotid endarterectomies under general anaesthetic because they find that it's more comfortable, well it's obviously going to be more comfortable for the patient because they don't feel anything during that procedure, but also that there's less movement, it's a more kind of controlled atmosphere and some surgeons will routinely place shunts in order to get around that problem of malperfusion of that section of the brain. So pros and cons to each approach and it depends on as I said surgeon preference and the confidence of the anaesthetist as well to place a block that will cover the area of the neck required to do the operation.