Carotid endarterectomy without protective measures in patients with occluded and non occluded contralateral carotid artery

BACKGROUND: Comparison of carotid endarterectomy in patients with and without occluded contralateral carotid artery. METHODS: Design: evaluation of results without using shunt or patch. Setting: Hospital, Medical School, University of Athens. Subjects: 235 patients, divided into group I of 40 patients with and group II of 195 patients without occluded contralateral carotid artery. Intervention: carotid endarterectomy under general anesthesia. Main outcome measures: heparin administration, stable hemodynamic status during clamping, short duration monitoring postoperatively. RESULTS: Postoperative morbidity of both groups was 2.5% (6/235) and mortality 1.7% (4/235). Group I: mortality rate was 2.5% (1/40) major and minor stroke each 2.5% (1/40) and group I: 1.5% (3/195) and 1% (2/195) respectively (NS). Four to 108 months later, 30% (12/40) of group I and 21% (41/195) of group II died. CONCLUSIONS: Endarterectomy of the carotid artery under general anesthesia without use of shunt and patch in patients with or without occlusion of the contralateral carotid artery presented the same comparative results. Candidates for carotid endarterectomy should be screened systematically for coronary disease preoperatively and annual stress testing postoperatively, tactics which may improve early and late mortality rate after carotid surgery.     

Regional anesthesia in elderly patients undergoing carotid surgery: report of a case series

BACKGROUND: This study evaluates the short-term results in patients more than 75 years of age undergoing carotid endarterectomy at a single institution. METHODS: Between June 2004 and June 2007, carotid endarterectomy operations were performed in 123 patients. A total of 70 patients had regional anesthesia. The data for all patients were retrospectively reviewed. Regional anesthesia and selective shunting was performed in all patients. RESULTS: In 6 patients, a shunt was required. Primary closure of the carotid artery was performed in 22 patients and patch angioplasty was used in the remainder. There were no postoperative neurological complications. One patient died due to myocardial infarction. CONCLUSIONS: Carotid endarterectomy with regional anesthesia can be performed safely in the elderly population with low mortality and morbidity. Regional anesthesia may have advantages over general anesthesia and could potentially aid in avoiding complications related to shunt use.     

The influence of anesthetic technique on perioperative complications after carotid endarterectomy

Purpose: This study evaluated the influence of anesthetic techniques on perioperative complications after carotid endarterectomy.Methods: Perioperative complications, the use of a carotid artery shunt, the duration of the operative procedure and postoperative hospital course were retrospectively compared in 584 consecutive patients undergoing 679 carotid endarterectomies with use of either general anesthesia (n = 361) or cervical block regional anesthesia (n = 318). There was no significant difference in the preoperative medical characteristics between the two anesthetic groups. Symptomatic carotid artery disease was the indication for surgery in 247 (68.4%) patients receiving general anesthetics, whereas 180 (56.6%) patients treated with a cervical block anesthetic had a symptomatic carotid artery stenosis (p = 0.02).Results: The perioperative stroke rate and stroke-death rate for the entire series was 2.4% and 3.2%, respectively, and was not significantly different between the anesthetic groups or between patients with symptomatic or asymptomatic disease. A carotid artery shunt was used in 61 (19.2%) patients receiving a cervical block anesthetic and 152 (42.1%) patients treated with a general anesthetic (p < 0.0001). Use of cervical block anesthesia was associated with a significantly shorter operative time, fewer perioperative cardiopulmonary complications, and a shorter postoperative hospitalization when compared with general anesthesia. Multivariate risk factor analysis indicated that age greater than 75 years, operative time greater than 3 hours, and the use of a carotid artery shunt were all independent risk factors for perioperative cardiopulmonary complications. When a carotid artery shunt was not analyzed as a multivariate risk factor, then general anesthesia became a significant risk factor for perioperative cardiopulmonary complications (risk ratio 2.08; p = 0.04).Conclusions: We conclude that cervical block anesthesia is safer and results in a more efficient use of hospital resources than general anesthesia in the treatment of patients undergoing carotid endarterectomy. (J VASC SURG 1994;19:834-43.)     

Local versus general anesthesia for carotid endarterectomy: report of 329 cases

Since stroke is an important cause of morbidity and mortality, carotid endarterectomies are used frequently to reduce the risk of stroke and death. Unfortunately, an inherent risk of the carotid endarterectomy procedure is that surgery itself may result in stroke. At this point the question is which method of anesthesia, local or general, is better to protect and monitorize the brain function during cross-clamp period in carotid endarterectomies? In the authors' center, 365 carotid endarterectomies were applied to 329 patients between 1990 and 2001; 165 operations were done under general anesthesia and the other 200 operations were done under local anesthesia. These 2 groups, general (group I) and local anesthesia (group II), were studied retrospectively according to preoperative and postoperative data. In group I, the rate of major stroke was 7.3%, but this rate was 1% in group II (p < 0.05). Intraoperative shunts were used in 50 (30.3%) operations of group I, but the usage of shunt was 8% (16 operations) in group II (p < 0.0001). The hospitalization period was also much shorter in group II than in group I. The time of hospitalization was 4.1 +/-1.9 days in group I and 2.4 +/-1.1 days in group II (p < 0.0001). In terms of cost analysis, the mean costs were 1007.14 dollars +/-135.71 dollars in group I and 885.71 dollars +/-78.57 dollars in group II (p < 0.0001). In short, the local procedure was more cost-effective. As a result, in carotid endarterectomy procedures, the authors prefer local anesthesia to achieve better brain function monitoring and to reduce hospitalization time and cost.     

Surgery of the carotid artery: locoregional anesthesia versus general anesthesia: Review of the literature

The aim of the study was to compare locoregional and general anesthesia in carotid artery surgery in order to establish whether differences exist in terms of perioperative results, use of intraoperative shunts and costs. Seventeen studies, comprising 14,776 carotid endarterectomies performed with either locoregional or general anesthetic and published over the period from 1990 to March 2000, were reviewed. There were no statistically significant differences in the cardiovascular risk factors of the patients. Neurological morbidity and mortality were similar in the two groups, even if the use of shunts in the locoregional anesthesia group was lower than in the general anesthesia group and in four studies was associated with a significant difference (P < 0.01). No statistical differences in cardiac morbidity or mortality were found between the groups, except in two studies. Additional randomised prospective trials are needed in large numbers of patients. Locoregional anesthesia appears to allow a limited use of intraoperative shunts, but with neurological mortality and stroke rates very similar to those in the general anesthesia group. Routine use of locoregional anesthesia makes it possible to lower the cost of carotid surgery without sacrificing quality.     

The impact of anesthetic modality on the outcome of carotid endarterectomy

BACKGROUND: Carotid endarterectomy (CEA) reduces the risk of stroke in patients with high-grade carotid artery stenosis. This study evaluates the clinical outcome of CEA performed under local anesthesia (LA) versus general anesthesia (GA). METHODS: Clinical variables and treatment outcomes were analyzed in 548 CEAs performed under either LA or GA during a 30-month period. Factors associated with morbidity were also analyzed. RESULTS: A total of 263 CEAs under LA and 285 CEA under GA were analyzed. The LA group was associated with a lower incidence of shunt placement, operative time, and perioperative hemodynamic instability compared to the GA group. No differences in neurologic complications or mortality were found between the 2 groups. Hyperlipidemia was a risk factor for postoperative morbidity in both the LA and GA groups, while age greater than 75 years was associated with increased overall morbidity in the GA group but not the LA group. CONCLUSIONS: This study demonstrates that increased age is associated with increased morbidity in CEA under GA, while hyperlipidemia is associated with increased morbidity in CEA regardless of the anesthetic choice.     

Carotid endarterectomy with contralateral carotid artery occlusion: is this a higher risk subgroup?

OBJECTIVE: to evaluate early and mid-term term results of carotid endarterectomy (CEA) in patient with and without contralateral carotid occlusion. METHODS: between 1996 and 1999, 1324 CEAs were performed. In 82 patients contralateral carotid artery occlusion was present (group I); 1242 patients had patent contralateral carotid (group II). All patients were operated under general anaesthesia, and selective shunting was based on somatosensory evoked potentials (SEPs). Ultrasonographic follow-up was performed at 1, 6 and 12 months and then once a year. Early results and follow-up data were analysed retrospectively. RESULTS: in group I there was a significantly higher incidence of SEPs reduction and shunt insertion; however, there were no differences in terms of perioperative complications. The cumulative stroke and death rate at 30 days in group 1 and group 2 were 2.4% vs 1.4% (p=n.s.), respectively. At a mean follow-up of 15 months there were no differences between the two groups in terms of cumulative symptom-free survival. CONCLUSIONS:the presence of contralateral carotid occlusion caused an increased use of shunt, but not in early complications rates.     

Efficacy and safety of percutaneous nephrolithotomy (PCNL): a prospective and randomized study comparing regional epidural anesthesia with general anesthesia

Objective: To compare the efficacy and safety of regional epidural anesthesia and general anesthesia in patients who underwent PCNL. Materials and Methods: Fifty patients submitted to percutaneous nephrolithotomy (PCNL) were randomized into two groups: Group I (N = 26) received general anesthesia and Group II (N = 24) received regional epidural anesthesia. Demographic and operative data including age, BMI, stone position, stone size, postoperative pain, amount of postoperative analgesic usage, length of hospital stay, patient satisfaction, preoperative and postoperative hemoglobin and hematocrit, adverse effects and surgical complications were compared between both groups. Results: Average pain score at 1 hour. was 6.88 in group I and 3.12 in group II (p < 0.001), at 4 hours. 5.07 in group I and 3.42 in group II (p = 0.025). Less morphine was required in the regional epidural anesthesia group compared to the general anesthesia group. Higher satisfaction was found in the regional epidural group. 6 (23.07 %) patients in Group I and 1 patient (4.19 %) in Group II had postoperative nausea and vomiting, respectively (p = 0.05). Pain score at 12 hours, 24 hours, 48 hours, 72 hours, preoperative and postoperative hemoglobin and hematocrit, length of hospital stay, and adverse effects were no different between the two groups. Conclusion: Regional epidural anesthesia is an alternative technique for PCNL which achieves more patient satisfaction, less early postoperative pain and less adverse effects from medication with the same efficacy and safety compared to general anesthesia.     

Arterial pressure and neurologic morbidity during carotid surgery under peridural anesthesia

In 163 carotid reconstructions under peridural anesthesia performed from 1988 to 1991, we routinely measured residual systemic and carotid artery pressure during clamping. Seventy-nine patients (48.5%) were asymptomatic and 84 (51.5%) had a history of neurologic manifestations in the form of transient ischemic attacks (28%) or stroke (13.5%). None of the patients died perioperatively. Eight patients (4.9%) had strokes, with complete recovery in five. A shunt was placed in 22 patients (13.5%) because of neurologic evidence that carotid clamping was poorly tolerated. This study showed a distinct association between residual pressure in the internal carotid artery and systemic arterial pressure and intraoperative neurologic morbidity. Using a cutoff value of 35 mm Hg for residual pressure, the sensitivity was 77% and specificity 81%. Using a cutoff of 80 mm Hg, the sensitivity was 60% and specificity 86%. There was no correlation between mean systemic arterial pressure and residual carotid artery pressure. The use of a shunt was the only factor with predictive value for postoperative neurologic complications. These findings suggest that measurement of systemic arterial pressure and residual carotid artery pressure is useful during carotid surgery, but further study is needed before this information can be extrapolated to carotid surgery under general anesthesia.     

Carotid surgery. Is regional anesthesia always appropriate?

We retrospectively studied a series of 385 carotid endarterectomies performed either under general anesthesia (242) or under local anesthesia (145) to compare the peri-operative mortality and morbidity rate and to identify factors which may influence the choice of anesthesia. The rate of transient ischaemic attacks (TIA), stroke, death, combined mortality, severe neurological and cardiac morbidity were not statistically different. Under general anesthesia, more shunts were inserted (17% versus 7%, p less than 0.05) and more myocardial infarctions occurred (5% versus 0%, p less than 0.05). However, more strokes due to technical imperfection were seen under regional anesthesia. We concluded that regional anesthesia is more appropriate in patients with coronary artery disease and in patients at risk of intolerance to cross clamping. General anesthesia is more appropriate in poorly cooperative patients or in those with unfavorable operative conditions.     

Asymptomatic carotid stenosis: selective or routine use of intraluminal shunt

BACKGROUND: To evaluate the use of temporary intraluminal shunt (IS) during operations in our patients for asymptomatic carotid stenosis (ACS) of the internal carotid artery (ICA). METHODS: Complications of ICA endarterectomy were reviewed in two groups of asymptomatic patients. In group A (144 patients, operation 1972-1985) temporary IS was used in 43 patients with the intraoperatively measured ICA back pressure <50 mmHg. In group B (170 patients, operation 1986-1998) shunt was used in all cases. RESULTS: The incidence of neurologic deficit was higher ia group A than in group B (5.6% vs 1.2%, p<0.05). Within group A, the incidence of neurologic deficit was significantly higher in the subgroup with back pressure >50 mmHg, and thus without shunt, than in group B with routine use of shunt (6.0% vs 1.2%, p<0.05). There were no differences in the incidence of shunt-related complications between the groups (3.0% vs 4.0%, p>0.05). We had no mortality after operations of asymptomatic patients. CONCLUSIONS: The routine use of IS reduced the rate of intraoperative and early postoperative neurologic complications of asymptomatic carotid endarterectomy, and it was not associated with a higher incidence of complications.     

Detailed comparison of regional and general anesthesia for carotid endarterectomy

Forty-one variables were examined in 75 patients who underwent carotid endarterectomy to determine if significant differences were present between 45 patients who had general anesthesia and 30 patients who had regional anesthesia. The two groups were similar in terms of age, existing medical illnesses, neurologic presentation, and angiographic severity of the carotid lesions. There were no differences between the two groups for operative time, anesthesia time, blood loss, maximum or minimum blood pressures, postoperative hemodynamic data, or the requirement for or duration of intravenous pressor or antihypertensive medications. One patient in the regional group had a postoperative neurologic deficit which resolved in 1 month. Three patients in the general group had cardiovascular complications. Postoperative hospital stay was significantly longer in the general anesthesia group (5.6 to 3.2 days, p = 0.003). Regional and general anesthesia produce similar perioperative hemodynamic and surgical outcomes, but regional anesthesia results in a shorter hospital stay and less cardiovascular morbidity in this high risk population.     

Is diabetes mellitus a risk factor for carotid endarterectomy? A prospective study

BACKGROUND: Although many randomized trials and other multicenter studies have demonstrated the benefits of carotid endarterectomy (CEA) in selected symptomatic and asymptomatic patients, several investigators have noted an increased rate of perioperative neurologic and cardiac morbidity in diabetic patients. To compare the perioperative outcome of CEA in diabetic patients (group I) versus nondiabetic patients (group II), we analyzed a consecutive series of CEAs performed by the same vascular surgeon at the same institution. METHODS: Data collection was prospective for all CEA procedures performed between August 1, 1992 and March 31, 1999. Group I and group II were matched for clinical presentation, percentage of internal carotid artery stenosis and indication for surgery. RESULTS: of 547 CEAs performed in 474 patients, 199 (36.4%) were in group I. Group I was younger at presentation than group II (P <.005) and women were in a higher proportion in group I than in group II (43.7% vs 27.1%, P =.0001). Although the incidence of peripheral atherosclerotic disease was comparable in the 2 groups, there was a significantly higher incidence of previous vascular surgery in group I (P =.01). Perioperative neurologic and cardiac morbidity rates were comparable in the 2 groups. The overall perioperative mortality rate was 0.5%. Long-term information was obtained in all patients (mean, 44 months; range, 1 to 75 months). No differences were found in the recurrent stenosis and occlusion rates between the 2 groups. Although there was no difference in the late mortality between the 2 groups, diabetic patients had a significantly higher cardiac-related death incidence (P =.01) than nondiabetic patients. CONCLUSIONS: The findings of this analysis indicate that CEA can be performed in diabetic patients with excellent perioperative morbidity and mortality rates and late stroke-free and survival rates that are comparable with those recorded in nondiabetic patients.     

Concomitant carotid endarterectomy and coronary bypass surgery: should cardiopulmonary bypass be used for the carotid procedure?

BACKGROUND AND OBJECTIVES: With the increasing age of patients undergoing coronary artery bypass grafting (CABG), a greater number have associated clinically significant carotid disease. This study determined the morbidity and mortality for combined carotid endarterectomy (CEA)/CABG using cardiopulmonary bypass (CPB) for both procedures versus a combined approach using CPB only during CABG. PATIENTS AND METHODS: Between 1993 and 2000, 65 patients (Group I) underwent combined CEA and CABG using CPB for both surgical procedures and 88 patients (Group II) underwent combined CEA and CABG using CPB only during CABG. The demographic, clinical, and carotid and coronary angiographic data were similar between groups. In Group I, 22 (33.8%) patients and 32 (36%) patients in Group II presented with contralateral carotid artery stenosis. RESULTS: CPB time was significantly longer in Group I, 127+/-21 minutes versus 98+/-11 minutes in Group II patients (p = 0.001). The incidence of surgical revision for bleeding and deep sternal wound infection was higher in Group I patients, 2 (3%) versus 1 (1.1%) and 5 (7.7%) versus 2 (2.2%), respectively, but not significant. Hospital mortality in Group I was 6% (4 patients) versus 5.7% (5 patients) in Group II (p = ns). Neurologic complications occurred in 4 (6%) and 5 (5.7%) patients in Group I and II, respectively (p = ns). Postoperative renal dysfunction was more common in Group I patients (22 [33.8%]) then in Group II patients 16 (19%) (p = 0.04). Of these patients, (16 [19%]) 8 (12.3%) in Group I and 6 (6.8%) in Group II required postoperative ultrafiltration (p = ns). Infectious complications were more frequent in Group I patients, 5 (7.7%) versus 2 (2.3%), but not statistically significant (p = ns). Overall actuarial survival at 1, 3, and 5 years, including all deaths, was 92%, 88%, and 82% in Group I versus 93%, 86%, and 81% in Group II (p = ns). Overall freedom from stroke at 5 years was 87.5% in Group I and 86.4% in Group II. CONCLUSIONS: We conclude that combined CEA/CABG using CPB only during the myocardial revascularization procedure remains the technique of choice in patients with coronary and carotid artery disease, offering better outcome in terms of perioperative morbidity than a combined CEA/CABG using CPB for both procedures.     

Eversion endarterectomy of the internal carotid artery: Midterm results of a new technique

A new eversion endarterectomy technique was used in 65 internal carotid artery reconstructions in 56 patients. The original features of the technique include a complete oblique transection of the internal carotid artery distal to the lesion and eversion endarterectomy through a longitudinal incision of the common carotid and external carotid arteries. The mean age of the patients was 68.2±7.8 years. Seventy-three percent of the patients had hypertension and 45.5% had coronary heart disease. Fifty-four percent experienced neurologic symptoms (transient in 36%, reversible in 6%, and permanent in 11%). Operations were performed under general anesthesia. An indwelling shunt was inserted whenever routine stump pressure was <50 mm Hg. There were no neurologic complications but one patient died of a compression hematoma of the neck, for a combined mortality and morbidity rate of 1.5%. Arteriograms were obtained from all patients on day 5 and showed complete restoration of normal anatomy in all cases and thrombosis of the external carotid artery in one. During a mean follow-up of 27 ± 4.7 months no strokes were observed. Follow-up duplex scans showed no hemodynamically significant restenoses. Eversion endarterectomy is a reliable alternative to other reconstruction procedures of the internal carotid artery.     

Anesthesia Technique and Outcomes of Endovascular Aneurysm Repair

Anesthetic techniques vary widely in the endovascular repair of abdominal aortic aneurysms (EVAR). Previous studies have demonstrated the feasibility of using local anesthesia. However, the ideal anesthetic technique has not been determined. This study examines whether anesthesic technique influences the outcomes of EVAR. Data regarding demographics, risk factors, procedural characteristics, recovery characteristics, treatment complications, acute (<30 day) medical complications, mortality, and anesthetic type were prospectively collected during the AneuRx phase II aortic endograft trial. Patient cohorts receiving general, regional, or local anesthesia were compared. From 1997 to 1998, 424 patients underwent EVAR at 13 sites using the AneuRx Bifurcated endograft. There were 279 patients in the general anesthesia group, 95 patients in the regional group, and 50 patients in the local group. Risk factors were similar. There were no significant differences in age, gender, American Society of Anesthesiologists grade, length of anesthesia, branch artery occlusions, proximal endoleaks, failed implants, or open surgical conversions. Cardiac, renal, and wound-healing complications were all lower in the local group. Mortality was equivalent among the three groups. (p > 0.05, ANOVA). From these results we concluded that EVAR with local anesthesia is a safe and efficacious method that may reduce recovery times and postoperative medical morbidity compared to use of genera1 or spinal/epidural anesthesia.     

Aortic arch anomalies are associated with increased risk of neurological events in carotid stent procedures.

OBJECTIVE: To establish the risk of carotid artery stent (CAS) complications in patients with aortic arch anomalies. METHODS: In a prospective series of patients submitted to CAS, all cases with arch anomalies were compared with cases with normal arch anatomy (type I, II and III) in order to assess the impact of anatomic characteristics on technical and clinical outcome. Outcome was evaluated in term of neurological complications and technical success. RESULTS: Of 214 consecutive patients undergoing CAS, 189 (88.3%) had normal arch anatomy and 25 (11.7%) arch anomalies. The arch abnormalities included common origin of brachiocephalic trunk and left common carotid artery in 22 cases (10.2%), separate origin of right subclavian and common carotid in 2 cases (0.9%) and left common carotid agenesis with separate arch origin of internal and external carotid in 1 case (0.5%). The two groups were not different in term of epidemiology and preoperative clinical and morphological characteristics. Technical failure occurred overall in 26 cases (12%) and neurological complication in 14 cases (6.5%). All symptoms were temporary. Technical failure was higher in the arch anomaly group; however the difference did not reach statistical significance (89.6% vs 76.4%, P=0.1). Neurological complications occurred more frequently in the arch anomaly group (20% vs 5.3%, P=0.039). Type of arch was the only variable independently associated with neurological complications (OR=2.01, p=0.026). CONCLUSION: Aortic arch anomalies are not infrequent and are associated with increased risk of neurological complications. The indication for CAS should be carefully evaluated in these cases.     

Concomitant Carotid Endarterectomy and Coronary Bypass Surgery: Should Cardiopulmonary Bypass Be Used for the Carotid Procedure?

Abstract Background and Objectives: With the increasing age of patients undergoing coronary artery bypass grafting (CABG), a greater number have associated clinically significant carotid disease. This study determined the morbidity and mortality for combined carotid endarterectomy (CEA)/CABG using cardiopulmonary bypass (CPB) for both procedures versus a combined approach using CPB only during CABG. Patients and Methods: Between 1993 and 2000, 65 patients (Group I) underwent combined CEA and CABG using CPB for both surgical procedures and 88 patients (Group II) underwent combined CEA and CABG using CPB only during CABG. The demographic, clinical, and carotid and coronary angiographic data were similar between groups. In Group I, 22 (33.8%) patients and 32 (36%) patients in Group II presented with contralateral carotid artery stenosis. Results: CPB time was significantly longer in Group I, 127 ± 21 minutes versus 98 ± 11 minutes in Group II patients (p = 0.001). The incidence of surgical revision for bleeding and deep sternal wound infection was higher in Group I patients, 2 (3%) versus 1 (1.1%) and 5 (7.7%) versus 2 (2.2%), respectively, but not significant. Hospital mortality in Group I was 6% (4 patients) versus 5.7% (5 patients) in Group II (p = ns). Neurologic complications occurred in 4 (6%) and 5 (5.7%) patients in Group I and II, respectively (p = ns). Postoperative renal dysfunction was more common in Group I patients (22 [33.8%]) then in Group II patients 16 (19%) (p = 0.04). Of these patients, (16 [19%]) 8 (12.3%) in Group I and 6 (6.8%) in Group II required postoperative ultrafiltration (p = ns). Infectious complications were more frequent in Group I patients, 5 (7.7%) versus 2 (2.3%), but not statistically significant (p = ns). Overall actuarial survival at 1, 3, and 5 years, including all deaths, was 92%, 88%, and 82% in Group I versus 93%, 86%, and 81% in Group II (p = ns). Overall freedom from stroke at 5 years was 87.5% in Group I and 86.4% in Group II. Conclusions: We conclude that combined CEA/CABG using CPB only during the myocardial revascularization procedure remains the technique of choice in patients with coronary and carotid artery disease, offering better outcome in terms of perioperative morbidity than a combined CEA/CABG using CPB for both procedures.     

Cardiac Outcome after Peripheral Vascular Surgery: Comparison of General and Regional Anesthesia

Background: Despite evidence that regional anesthesia may be associated with fewer perioperative complications than general anesthesia, most studies that have compared cardiac outcome after general or regional anesthesia alone have not shown major differences. This study examines the impact of anesthetic choice on cardiac outcome in patients undergoing peripheral vascular surgery who have a high likelihood of associated coronary artery disease.

Methods: Four hundred twenty-three patients, between 1988 and 1991, were randomly assigned to receive general (n = 138), epidural (n = 149), or spinal anesthesia (n = 136) for femoral to distal artery bypass surgery. All patients were monitored with radial artery and pulmonary artery catheters. Postoperatively, patients were in a monitored setting for 48-72 h and had daily electrocardiograms for 4-5 days and creatine phosphokinase/isoenzymes every 8 h x 3, then daily for 4 days. Cardiac outcomes recorded were myocardial infarction, angina, and congestive heart failure.

Results: Baseline clinical characteristics were not different between anesthetic groups. Overall, the patient population included 86% who were diabetic, 69% with hypertension, 36% with a history of a prior myocardial infarction, and 41% with a history of smoking. Cardiovascular morbidity and overall mortality were not significantly different between groups when analyzed by either intention to treat or type of anesthesia received. In the intention to treat analysis, incidences of cardiac event or death for general, spinal, and epidural groups were 16.7%, 21.3%, and 15.4%, respectively. The absolute risk difference observed between general and all regional anesthesia groups for cardiac event or death was -1.6% (95% confidence interval -9.2%, 6.1%) This reflected a nonsignificant trend for lower risk of postoperative events with general anesthesia.     

Does contralateral carotid occlusion influence neurologic fate of carotid endarterectomy?

Divergent opinions regarding operative risks and late prognosis of patients undergoing endarterectomy for carotid stenosis with contralateral carotid occlusion have prompted a review of the experience at Emory University Hospital from Jan. 1, 1978, through Dec. 31, 1982. Fifty-four patients (37 men, 17 women; mean age 63 years) who underwent carotid endarterectomy (CEA) with contralateral carotid occlusion (group I) were compared with 410 demographically similar patients without contralateral carotid occlusion (group II) who underwent 503 CEAs during the same interval. CEA indications in group I were the following and were proportionately similar to those of group II: hemispheric transient ischemic attacks, 22 patients; asymptomatic stenosis, 12 patients; nonhemispheric symptoms, 11 patients; previous cerebral infarction, eight patients; and vascular tinnitus, one patient. General anesthesia, routine intraluminal shunting, systemic heparinization, and arteriotomy closure without patch were routinely employed in both groups. Three patients in group I suffered permanent neurologic deficits after operation (5.6%) and two had transient postoperative deficits with complete recovery. Ten patients (2.0%) in group II suffered permanent neurologic deficits and 10 patients experienced transient neurologic events after operation. Neither the transient nor the permanent neurologic deficit rates were statistically different (p greater than 0.05; Fisher exact test) in the two groups. Operative mortality rates for group I and group II were 0% and 0.8%, respectively, and were not significantly different (p greater than 0.10; Fisher exact test). Late postoperative ischemic brain infarctions occurred in two patients in group I (3.8%) and in 13 patients (3.6%) in group II (p greater than 0.10; Fisher exact test). Kaplan-Meier survival analyses were virtually identical in both groups, with the majority of deaths caused by cardiac occlusion may undergo CEA with morbidity and mortality rates similar to those without contralateral occlusions. Contralateral carotid occlusion does not necessarily portend an unfavorable early or late prognosis after CEA.