Hemodynamic Changes in Patients Undergoing Carotid Endarterectomy under Cervical Block and General Anesthesia

Abstract

The objective of this study was to assess differences in hemodynamic stability for patients undergoing carotid endarterectomy (CEA) under general anesthesia (GA) as compared with cervical block anesthesia (CBA). An institutional review board-approved, retrospective review of 651 patients from 1998 to 2012 undergoing CEA was performed: 254 patients underwent CEA under CBA and 397 under GA. Comprehensive chart review including preoperative, postoperative, and 30-day follow-up was conducted. Patients were monitored continuously intraoperatively and for 24hr after surgery. All intraoperative vasoactive and antihypertensive medications administered were recorded. Both groups were similar in age, incidence of coronary artery disease, hypertension, and renal failure. There was a preponderance of female patients, with a high incidence of chronic obstructive pulmonary disease, diabetes mellitus, and nicotine abuse in the GA group. Symptomatic patients predominated the GA group (54% vs. 41%; P=0.0018). Of the symptomatic patients, 78% experienced transient ischemic attacks in the GA group vs. 64% in the CBA group. Evaluation of hemodynamic stability under GA versus CBA revealed that no significant hemodynamic changes occurred in 34.5% of CBA patients vs. only 14.4% in the GA group. Under GA, incidence of hypotension was 17.84% as compared with 0.52% under CBA (P<0.001). Under GA, patients had far more hemodynamic fluctuations with 41% of patients demonstrating >3 intraoperative fluctuations in mean arterial pressure of >20% vs. 20% in the CBA group (P<0.001). Under GA, 51% of patients required vasopressors alone vs. 36% under CBA (P<0.0002). Antihypertensive medications alone were required in 63% of patients in the GA group vs. 73% in the CBA group (P=0.0085). Thirty percent of all patients required both vasopressors and antihypertensives during surgery; 23% under CBA vs. 34% under GA (P=0.0457). There were two postoperative hematoma's CBA cohort. The GA cohort developed postoperative complications (myocardial infarction, 4; stroke, 6; and hematoma, 9), however, these complications were not statistically significant compared with the CBA group. For patients undergoing CEA, CBA resulted in less hemodynamic fluctuations and fewer intraoperative vasoactive medication requirements as compared with GA.