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.)     

The influence of anesthetic choice on carotid endarterectomy outcome

This study compared the technique of general and regional cervical block anesthesia for carotid endarterectomy. Three hundred sixty-eight patients undergoing 399 carotid endarterectomies were administered one of these alternative anesthetics as selected preoperatively by each patient and his or her physician. In 242 cases general anesthesia was used. The other 157 cases were done under regional cervical block anesthesia. Perioperative mortality was 1.0%. Nonfatal strokes occurred in 1.25%. There were significantly more strokes in the general anesthesia group. Perioperative blood pressure was unstable for a significantly longer period of time after general anesthesia (mean, 24.6 hours) as compared with regional cervical block anesthesia (mean, 2.1 hours). Furthermore, vasoactive drugs were required for significantly longer periods of time in the general anesthesia group.     

The effects of regional and general anesthesia on blood pressure control after carotid endarterectomy

We retrospectively reviewed the influence of preoperative blood pressure control and regional vs. general anesthetic techniques on the incidence of intraoperative and postoperative (recovery room and intensive care unit) hypotension and hypertension in 249 carotid endarterectomy patients. Preoperative blood pressure was classified as uncontrolled hypertension (systolic blood pressure >/= 170 mm Hg and/or diastolic blood pressure >/= 95 mm Hg), controlled hypertension (blood pressure <170/95 mm Hg on chronic antihypertensive therapy), or normotension (blood pressure <170/95 mm Hg without antihypertensive therapy). Hypotension, as defined by the requirement for vasopressor administration to maintain a systolic blood pressure of at least 120 mm Hg, occurred more frequently after regional than after general anesthesia (p < 0.05). Postoperative hypertension was defined as a systolic blood pressure >/= 200 mm Hg and/or a diastolic blood pressure >/= 110 mm Hg in the recovery room or in the Intensive Care Unit. Preoperative hypertension was not associated with acute postoperative hypertension in the intensive care unit in either the regional anesthesia (n = 190) or the general anesthesia (n = 59) groups, although with either type of anesthesia, preoperative hypertension was associated with an increased incidence of hypertension in the recovery room (p < 0.01 regional; p < 0.005 general).     

Long-term effect of carotid endarterectomy on carotid sinus baroreceptor function and blood pressure control

In order to assess whether carotid endarterectomy had any long-term hypotensive effect, by altering the function of the carotid sinus baroreceptors, blood pressure and carotid sinus baroreceptor function were recorded in 25 patients undergoing carotid endarterectomy. No overall change in blood pressure was recorded 6 months after surgery. Sinus function was shown to decrease in 2 (8 per cent), to remain unchanged in 15 (60 per cent) and to increase in 8 (32 per cent) patients 6 months postoperatively. There was no relationship between changes in sinus function and changes in blood pressure over the 6 months period. Thus, carotid endarterectomy has no long-term hypotensive effect.     

Noninvasive perioperative monitoring of carotid endarterectomy

Doppler ultrasound and supraorbital photoplethysmography were used to screen 79 patients undergoing 87 carotid endarterectomies in the perioperative period. Supraorbital photoplethysmography permitted continual monitoring of ophthalmic artery flow dynamics throughout the operation on 14 patients. The ratio of supraorbital pulse amplitude during and prior to carotid clamping correlated well with the carotid back (stump) pressure (R = 0.87, P < 0.001). A sterile Doppler probe permitted assessment of the integrity of carotid endarterectomy during the operation. Postoperative screening by Doppler ultrasound identified asymptomatic residual obstruction in six external carotid arteries (6.9%) and four internal carotid arteries (3.4%). Noninvasive perioperative screening of patients undergoing carotid endarterectomy provides useful information to assess the efficacy of this reconstructive procedure.     

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.     

The influence of gender on complications of carotid endarterectomy

PURPOSE: Carotid endarterectomy (CEA) effectively reduces stroke risk in properly selected patients. Subgroup analysis of the Asymptomatic Carotid Artery Study trial noted increased complications in women. Additional studies implicate female gender as a risk factor for perioperative stroke, leading some clinicians to modify the indications for CEA in women. The purpose of this study was to determine the influence of gender on the risk of perioperative complications in patients undergoing CEA. METHODS: The records of all patients who underwent CEA at a university medical center from January 1995 to December 1999 were reviewed. Patient demographics, procedure related risk factors, operative details, and specific complications were entered into a database for statistical analysis. RESULTS: A total of 324 consecutive patients underwent CEA during the study period. There were 199 men (61%) and 125 women (39%). Among the men and women, there were no differences in age, smoking, hypertension, hypercholesterolemia, diabetes, family history, renal insufficiency, or symptomatic versus asymptomatic indications for CEA. More women than men received a carotid patch (90.4% versus 77.9%, P = 0.003). One woman died (0.8%) and no men died for a total combined 30-day mortality of 0.31% (P = not significant). Men and women did not differ in rates of stroke (1.5% versus 2.4%) or perioperative myocardial infarction (1.0% versus 0.8%). In addition, there was no difference when stroke and death rates were combined (2% versus 3.2%). The length of stay (2.2 versus 2.6 days) was also not different. CONCLUSIONS: There are no significant differences in rate of stroke, myocardial infarction, or 30-day mortality, between men and women following CEA. Women should not be excluded from the benefits of CEA based on perceived increased complication rates.     

Evaluation of carotid distal pressure for prevention of hyperperfusion after carotid endarterectomy

BACKGROUND: Sometimes preoperative cerebral misery perfusion induces an occurrence of hyperperfusion after carotid endarterectomy (CEA). We intraoperatively measured carotid proximal and distal pressures and evaluated their role in predicting hyperperfusion. METHODS: Twenty-one sites with an indication of CEA were preoperatively assessed based on the bilateral perfusional state of the cerebral blood flow (CBF) and delta CBF by single photon emission computed tomography (SPECT). Postoperative SPECT was performed immediately and on the fifth day after surgery. The distal and proximal pressures were intraoperatively measured through an internal shunt tube, and the evaluated relationship against hyperperfusion was shown on postoperative SPECT. RESULTS: Despite strict control of blood pressure, 7 patients postoperatively showed hyperperfusion on SPECT and 2 of them had transient neurological symptoms. The distal pressure was significantly different between the postoperative hyperperfusion group and the normal one; however, proximal pressure and the difference between proximal and distal pressures were not significantly different. In the hyperperfusion group, delta pressure was apparently higher, and delta CBF and distal pressure were significantly lower than those of the normal group. CONCLUSION: Intraoperative measurement of distal pressure as well as preoperative estimation of the cerebrovascular perfusion and the reserve is of importance in predicting postoperative hyperperfusion.     

Perioperative blood pressure alterations after eversion and conventional carotid endarterectomy sustain in the midterm

Objective

Carotid endarterectomy (CEA) is associated with a profound effect on blood pressure. The aim of this study was to evaluate 24 h ambulatory blood pressure measurement (ABPM) after eversion (E-CEA) and conventional (C-CEA) endarterectomy including a midterm follow-up.

Methods

Seventy-one patients were included in this prospective study [E-CEA (37)/C-CEA (34)]. Daytime (8 a.m. to 10 p.m.) and nighttime (10 p.m. to 8 a.m.) ABPMs were analyzed perioperatively and at midterm after a median follow-up period of 9.5 months (interquartile range (IQR) 6.4–17.8) in the E-CEA group and 11.5 months (IQR 8.3–13.6) in the C-CEA group

Results

Patient demographics and preoperative antihypertensive regimens were similar in the two groups. Compared with baseline, ABPM decreased on postoperative day 1 in the C-CEA group (P?<?0.01) but normalized by day three. By contrast, ABPM values were unchanged on day 1 in the E-CEA group but increased above baseline on day 3 (P?<?0.01). E-CEA was associated with higher ABPM on day 1 (P?<?0.001 daytime, P?<?0.01 nighttime) and again on day 3 (P?<?0.001 daytime, P?<?0.01 nighttime). The use of vasodilators was more frequent in the E-CEA group, both in the recovery room (P?=?0.007) and on the ward (P?=?0.004). Midterm results showed no difference of average blood pressure values, but an increased maximal blood pressure (P?=?0.01 daytime) and heart rate (HR) (P?=?0.006 daytime) were reached in the E-CEA group and decreased HR (P?=?0.01 nighttime) in the C-CEA group. Compared with baseline [(E-CEA: median (IQR) 2 (1–3); C-CEA: median (IQR) 2 (1–3)], the number of antihypertensive medications at midterm was significantly higher in the E-CEA group [(median (IQR) 3 (2–3) vs. 2 (2–3), P?=?0.002)]. In both groups, no adverse cardiovascular or cerebrovascular events during follow-up could be observed.

Conclusion

Although the initial hypertensive effect of E-CEA diminishes during midterm follow-up, patients undergoing eversion endarterectomy keep needing more antihypertensive medications and are prone to develop higher maximal blood pressure.     

Association of sex with perioperative mortality and morbidity after carotid endarterectomy for asymptomatic carotid stenosis

OBJECTIVE: To examine whether perioperative morbidity and mortality after carotid endarterectomy depend on the sex and the presence of symptoms on presentation. DESIGN: Retrospective review of quality assurance database prospectively collected. SETTING: A university teaching hospital. PARTICIPANTS: One thousand two hundred eighty-seven patients who had 1,503 carotid endarterectomies from 1990 to 1999 from a quality assurance database. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The cases were divided into 4 groups by sex and symptoms on presentation: male-symptomatic (MS), male-asymptomatic (MA), female-symptomatic (FS), and female-asymptomatic (FA). The 4 groups were compared for preoperative demographic and comorbidity profiles, carotid plaque characteristics, and outcome. Outcome measures included in-hospital stroke, myocardial infarction (MI), congestive heart failure (CHF), and death. There were 496 cases in the MS group, 407 in the MA group, 315 in the FS group, and 285 in the FA group. Women were less likely to have a history of coronary artery disease, prior MI, or smoking, and their carotid plaques were less likely to be ulcerated or contain intraplaque hemorrhage. Even when controlling for the comorbidities and plaque characteristics, the incidence of each of the complications examined was low and not significantly different between the sexes in both the symptomatic and asymptomatic groups. The rate of stroke or death was 3.0% (MS) versus 1.9% (FS) (p = NS) and 1.2% (MA) versus 1.8% (FA) (p = NS). CONCLUSION: There is no significant sex difference in perioperative cardiac or cerebrovascular complications. Women with symptomatic or asymptomatic carotid stenosis can have acceptably low complication rates from carotid endarterectomy and may benefit from the surgery as much as men.     

The influence of neutralizing heparin after carotid endarterectomy on postoperative stroke and wound hematoma

The influence of neutralizing or not neutralizing heparin after carotid endarterectomy on postoperative stroke and wound hematoma is unknown. During the past 6 years some of the authors frequently gave protamine sulfate to neutralize heparin, whereas others did not unless a patch was used or wound hemostasis was not readily obtained. To determine the influence of protamine sulfate on stroke and wound hematoma the records of 697 patients having a carotid endarterectomy from January 1984 to September 1989 were reviewed. Protamine sulfate was given to 328 patients, and 369 did not receive protamine sulfate. The incidence of stroke in the two groups was 1.8% (n = 6) and 2.7% (n = 10), respectively, and the difference was not significant (p = 0.6019). Excluding three strokes that could not be related to neutralizing or not neutralizing heparin, the difference remained insignificant (1.5% vs 2.2%, p = 0.7290). The incidence of wound hematoma was 1.8% (n = 6) in patients given protamine sulfate and 6.5% (n = 24) in patients not given protamine sulfate, and this difference was significant (p = 0.0044). The difference remained significant when three hematomas not related to protamine sulfate were excluded (1.2% vs 6.2%, p = 0.0013). In patients not given protamine sulfate draining the wound lessened the incidence of wound hematoma (4.4% vs 8.6%), but this difference was not statistically significant (p = 0.1475). In patients given protamine sulfate the dose of protamine sulfate (15 to 45 mg vs 50 to 75 mg) had no statistically significant effect on the incidence of stroke (0.8% vs 2.0%, p = 0.6530) or wound hematoma (1.6% vs 1.0%, p = 1.000).     

SIADH after carotid endarterectomy

The syndrome of inappropriate secretion of antidiuretic hormone after carotid endarterectomy is very rare; only two cases have been reported in medical literature. We describe the case of an 82-year-old woman presenting with lethargy and drowsiness due to severe hyponatremia with urine hyperosmolarity and plasma hypo-osmolarity after carotid endarterectomy.