Carotid endarterectomy under local anesthesia

Results of carotid endarterectomy (CEAE) in 193 patients with different degree of cerebrovascular insufficiency were analyzed. All the patients were men with carotid atherosclerosis (age from 39 to 68 years, mean age 53.6 +/- 0.4). A total of 253 CEAEs were performed under local anesthesia (60 patients underwent consecutive bilateral operations). In early postoperative period 3 patients died, one of them--of ischemic stroke due to thrombosis of internal carotid artery on the side of the operation. Non-fatal stroke was in 1 patient. There were no intraoperative cerebral complications. This testifies to reliability of cerebral circulation control through direct contact with patient.     

Carotid endarterectomy under regional (conductive) anesthesia.

Carotid endarterectomy is reliable in the prevention of strokes due to arteriosclerotic disease at the carotid bifurcation. This is a retrospective review of 314 carotid endarterectomies performed at the University Health Center of Pittsburgh. The objectives of the study were to determine if regional anesthesia was a safe technique for carotid endarterectomy and to determine whether the neurologic complications that occurred were embolic or ischemic in origin. In patients who were neurologically intact before operation, the perioperative mortality was 0.88% and the incidence of neurologic complications was 3.1%. This is comparable to the current literature. Observations of the awake patient suggested that half the neurologic deficits that occurred in this series were due to embolization rather than to cerebral ischemia. Further more, the incidence of non-neurologic complications under general anesthesia was 12.9%. Under regional anesthesia, the incidence of non-neurologic complications was 2.8%. The data supports carotid endarterectomy under regional block as safe and reliable method.     

Carotid endarterectomy under local anesthesia: single institutional experience

The aim of this study is to review our experience and results of carotid endarterectomy performed under local anesthesia. We evaluated 300 patients who had undergone carotid endarterectomy with local anesthesia in our department. Surgical indication, outcome, operative technique, and complications were assessed. The patients were 58.20+/-2.76 years old and 153 (51%) were symptomatic. The perioperative course was uneventful. A shunt was inserted because of neurological deterioration in 20 patients (6.6%) with full recovery of the deficit after shunt insertion. Operative time was 52.02+/-12.86 min. There were 9 patients with postoperative neurological complications with one patient who died after 34 days. The remaining 8 patients with reversible neurological deficits recovered and were symptom-free on discharge. The mean length of hospital stay was 2.11+/-1.34 days. Carotid endarterectomy performed under local anesthesia is associated with low morbidity and mortality rates. The surgeon can assess the neurological status during the procedure and provide for a more meticulous endarterectomy. It is also associated with decreased shunt usage, decreased operative time and shorter length of hospital stay.     

Carotid endarterectomy with regional anesthesia

The senior author (REH) has changed his technique for performing carotid endarterectomy from the use of general anesthesia to the use of cervical block anesthesia. Because a randomized study was not performed, it is difficult to separate effects of increased surgical experience from those caused by a change in anesthetic regimen. Nonetheless, there has been a substantial decrease in complications, length of hospital stay, and costs concomitant with the change to regional anesthesia; we think there is a causal relationship. The use of cervical block anesthesia has practically eliminated the non-stroke-related complications associated with carotid endarterectomy in our practice. The technique for performing carotid endarterectomy under cervical block anesthesia is described in detail.     

Carotid endarterectomy using regional anesthesia

The author has had considerable experience with the use of general anesthesia and regional anesthesia for patients undergoing carotid endarterectomy. His experience and a review of the literature indicate that the use of regional anesthesia significantly reduces the incidence of nonsurgical complications following operation. A particularly robust effect is placed on reducing cardiopulmonary complications.     

Carotid endarterectomy under cervical plexus block--a prospective clinical audit

One hundred and twenty-eight patients having carotid endarterectomy under superficial and deep cervical plexus blocks were prospectively audited. The aim of the audit was to determine the incidence of intra-operative and postoperative neurological and cardiovascular complications and to establish patient acceptance of the technique. Twenty-seven patients who had intra-operative neurological changes following carotid artery clamping responded to shunt insertion. Six patients had transient neurological changes after the operation but there were no permanent neurological complications. Tachycardia (55%) and hypertension (67%) were the most common intra-operative cardiovascular changes and there was one clinical postoperative myocardial infarction. Ninety-two per cent of patients who could be adequately assessed preferred to have the same method of anaesthesia for future carotid endarterectomy. The authors concluded that carotid endarterectomy under superficial and deep cervical plexus blocks was associated with a high patient acceptance, low neurological complication rate and an acceptable rate of cardiovascular complications.     

Carotid endarterectomy: neurologic complications as related to surgical techniques.

Three hundred seventeen carotid endarterectomies performed on 240 consecutive patients in four Charleston hospitals were reviewed. The overall incidence of stroke was 10.7% and the mortality 3.2%. From these 317 operations a standardized series of 253 operations performed on neurologically stable patients was analyzed for neurologic complications as related to the use of an intra-operative shunt. Additional factors studied were length of time of carotid occlusion and degree of contralateral carotid stenosis. From the standardized series the incidence of stroke in 137 shunted cases was 9.5%, and in 116 non-shunted cases was 0.9%, a significant difference (p less than 0.01). Carotid artery occlusion times from 30 seconds to 12 minutes in the shunted group, and three minutes to 24 minutes in the non-shunted group had no relationship to the incidence of stroke. Significant contralateral carotid artery stenosis, present in 28/137 shunted cases and 30/116 non-shunted cases, had no predictive value in the development of a stroke. The use of an intra-operative shunt did not protect against stroke in these patients.     

Optimal cerebral monitoring during carotid endarterectomy: neurologic response under local anesthesia

A prospective series of carotid endarterectomies were performed with patients given local anesthesia in an attempt to determine the efficacy of intraoperative EEG monitoring and/or stump pressure measurements in predicting the need for carotid shunting. Carotid artery stump pressure was measured and EEG changes noted; however, neither low stump pressure nor EEG changes influenced the decision for shunt insertion. A shunt was only used if a neurologic deficit developed during carotid clamping. A total of 134 carotid endarterectomies were done in 121 patients. Sixty-six patients were men and 55 were women with ages ranging from 41 to 88 years. Indications included transient ischemic attacks in 57 (43%), prior stroke in 25 (19%), vertebrobasilar symptoms in nine (6%), and asymptomatic patients with high-grade stenosis, 43 (32%). Thirteen patients (9.7%) developed neurologic deficits following carotid clamping and had shunts inserted. All deficits cleared following shunt insertion. Nine of the 13 had EEG changes, but in four, EEGs were unchanged despite the occurrence of clear-cut neurologic changes. Stump pressure in the 13 patients ranged from 14 to 78 mm Hg. Ten were greater than 24 mm Hg and three were more than 50 mm Hg. In 121 operations no neurologic deficits occurred during carotid clamping and no shunts were inserted. In 13 of these operations, significant EEG changes were noted. Stump pressures in these 13 with EEG changes ranged from 15 to 120 mm Hg. In seven, stump pressure was greater than 50 mm Hg. There were no deaths in the series. Two (1.5%) temporary and one (0.7%) permanent postoperative deficits occurred.(ABSTRACT TRUNCATED AT 250 WORDS)     

Carotid endarterectomy under remifentanil]

OBJECTIVE: Carotid endarterectomy can be performed under general or locoregional anesthesia. If locoregional anesthesia is chosen, the state of awareness of the patient allows for direct viewing of the effect of vascular clamping of the corresponding neurological territory. We present the results of an anesthetic procedure using only an analgesic in patients who were intubated and ventilated but with a level of consciousness that allowed us to view the effect of carotid clamping on motor functions. METHOD: Forty-eight patients, ASA II-III, underwent surgical carotid endarterectomy. The anesthetic protocol began with preoxygenation for 2 min; induction with remifentanil 0.75-1 microgram kg-1 for 2 min., followed by perfusion of 1 microgram/kg-1.min-1 of remifentanil and propofol 1 microgram/kg-1; and orotracheal intubation by local anesthesia of the glottis with 5% lidocaine spray. Ventilation was with FiO2 100%, FR 12 min. and VT 8 ml. kg-1. For maintenance the dose of remifentanil was regulated to obtain a coordinated motor response (maximum 1.5 microgram/kg-1.min-1, minimum 0.35 microgram/kg-1. min-1). For all patients we monitored hemodynamics continuously and non-invasively, including aortic output by the transesophageal Doppler echocardiography. RESULTS: The objective of anesthesia was reached in all the patients. The most common hemodynamic alterations were bradycardia (28), arterial hypotension (25), elevated blood pressure (3) and altered aortic output. All changes were corrected quickly with the treatment used, guided by the evolution of hemodynamic parameters. Postanesthetic recovery came in less than 4 min. The only episodes of hyper -and hypotension consisted of a few episodes of mild hyper- (12) and hypotension (1), which were soon corrected. No alterations attributable to hemodynamic instability occurred. During surgery, an intracarotid shunt was necessary in only one patient. Three suffered surgically-related neurological complications after the operations. No complications could be attributed to anesthesia. DISCUSSION: An advantage of this technique is that the duration of anesthesia is not limited, with adequate ventilation and maintenance of an adequate state of consciousness for clinical evaluation of the repercussions of carotid clamping. Hemodynamic monitoring detected the appearance of imbalances requiring therapeutic intervention. The procedure is interesting provided it is performed according to a strict protocol, with continuous clinical and instrumental monitoring of the patient's status.     

Converting from general anesthesia to cervical block anesthesia for carotid endarterectomy.

Between January 1, 1992 and June 30, 1998, vascular and general surgery residents performed 401 carotid endarterectomies (185 cervical block, 216 general anesthesia) under supervision of vascular attending surgeons. In January 1995, cervical block anesthesia was newly instituted. Initially anesthesiologists were randomly assigned to these cases and anesthetic technique was not standardized. At the surgeons' insistence later in the series, three specially trained anesthesiologists routinely administered cervical block anesthesia. As experience grew, surgeons realized that operating time greater than 2 hours and high neck dissections requiring mandibular retraction were poorly tolerated by cervical block anesthesia patients but that repeat carotid endarterectomies could be safely performed. Shunts were selectively inserted if significant electroencephalographic changes occurred or carotid stump pressures were less than 50 mm Hg systolic when general anesthesia was used; neurologic changes occurred when cervical block anesthesia was used; or there was a history of ipsilateral stroke for either anesthetic method. Despite an initial learning curve with cervical block anesthesia, the stroke-mortality rate was similar between the two groups (general anesthesia: 1.9% [four cerebrovascular accidents, two deaths]; cervical block anesthesia: 1.6% [two cerebrovascular accidents, two deaths]). Eight (12%) of the first 66 cervical block anesthesia patients were converted to general anesthesia compared to 2 (1.7%) of the most recent 119 patients with cervical block anesthesia (p = 0.03). After cervical block anesthesia was initiated, seven of the first eight repeat carotid endarterectomies were performed using general anesthesia compared to one of the most recent six repeat cases (p = 0.02). As surgeons' comfort with cervical block anesthesia increased, 94% (100) of the most recent consecutive 106 carotid endarterectomies were performed using this technique. These results suggest that carotid endarterectomy can be performed as safely using cervical block anesthesia as general anesthesia, specialized anesthesiologists are essential to achieve a successful outcome, selected repeat carotid endarterectomies can be performed using cervical block anesthesia, very cephalad lesions are best treated using general anesthesia, and surgical trainees can safely perform carotid endarterectomy under attending surgeon supervision if the operation is carried out expeditiously.     

全麻和颈丛阻滞行颈动脉内膜剥脱术的对比研究

目的比较全麻和颈丛阻滞行颈动脉内膜剥脱术(CEA)围术期血液动力学变化和并发症情况.方法64例颈动脉内膜剥脱术分别在全麻和颈丛阻滞下完成,每组32例.记录并计算两组围术期血液动力学参数的波动性,分流管使用率、心脑并发症,询问患者的满意程度和选择倾向.结果CEA全麻围术期的血液动力学波动性明显大于颈丛阻滞(P＜0.01),高血压和低血压的发生率也高于颈丛阻滞(P＜0.05);全麻分流管的使用率高于颈丛阻滞(P＜0.05),围术期心肌缺血的发生率也高于颈丛阻滞(P＜0.05),两组神经系统并发症无显著差异.患者对两种麻醉方法的满意程度无显著差异,倾向于选择已使用过的麻醉方法.结论全身麻醉和颈丛阻滞都可安全用于颈动脉内膜剥脱术,颈丛阻滞有利于维护围术期血液动力学的稳定,减少分流管的使用和心血管并发症.