Regional Anesthesia For Carotid Endarterectomy Research Articles

Carotid endarterectomy using regional anesthesia: technique and considerations.

Carotid endarterectomy (CEA) is one of the most effective operations in minimizing stroke risk in both symptomatic and asymptomatic patients with carotid stenosis in the United States. Awake CEA with regional anesthesia may decrease both perioperative complications and length of hospital stay. Techniques of performing awake CEA is not often described in published literature. To describe our experience with CEA using regional anesthesia with a focus on patient selection, anatomic variations, and surgical technique including cervical regional block. We particularly focus on nuances of the awake approach. CEA using regional anesthesia is described in detail. Successful use of regional anesthesia during CEA without complication. Regional anesthesia for CEA is an advantageous approach for cervical plaque removal in appropriate patients. Thoughtful patient selection, as well as understanding of anatomy and its variants, is required. Potential advantages and disadvantages are discussed.

Experience With Regional Anesthesia for Carotid Endarterectomy at the N.V. Sklifosovsky Research Institute for Emergency Medicine

Acute cerebrovascular accident is one of the major causes of death and disability of patients around the world. In 30-40% of cases, the cause of ischemic stroke is an extracranial lesion of the brachiocephalic vessels. Carotid endarterectomy is the main technique for preventing cerebrovascular accident in carotid artery stenosis. General anesthesia with endotracheal intubation has been the method of choice since the widespread introduction of this type of surgical intervention into clinical practice and in most centers remains so to this day. At the same time, many authors report, that the use of general anesthesia with endotracheal intubation has limitations in a number of patients, namely, in the presence of an embologenic plaque in the operated internal carotid artery, severe coronary artery disease, decompensated aortic and / or mitral stenosis, low ejection fraction, heart rhythm and conduction disorders, severe chronic diseases of the respiratory system, as well as patient refusal for general anesthesia.THE AIM of the study was to show the possibilities of using regional anesthesia for carotid endarterectomy in a high-risk patient.RESULTS The use of regional anesthesia allows surgeons to avoid instability or abrupt changes in hemodynamics in the intraoperative period. Indications for its use are also cases of critical contralateral stenosis of the internal carotid artery when it is necessary to carefully consider the advisability of installing an internal stent.CONCLUSION The use of regional anesthesia made it possible to successfully perform carotid endarterectomy without cardiovascular events, neurological deficit and postoperative complications in a patient with relative contraindications to general anesthesia.

CAROTID ENDARTERECTOMY WITH REGIONAL ANESTHESIA IN OUR EXPERIENCE

Aim: Carotid endarterectomy (CEA) is a common revascularization option for carotid atherosclerosis. Regional anesthesia for CEA has become a preferred anesthesia technique in lots of centers. In this study, we present our experience with CEAs under regional anesthesia.
 Material and Methods: From 2019 to 2022, 271 patients who underwent CEA with regional anesthesia in two centers were included. Retrospectively, patient data, demographical characteristics, comorbidities, and radiological imaging features were enrolled by searching the hospital information system. The primary endpoint was to describe the outcomes.
 Results: Of the 271 participants, 202 were male and 69 were female. The male-to-female ratio is 74.5. The average age was 65.3±10,2. General anesthesia was maintained for two patients due to inadequate patient collaboration. The average operation time was 52±8.9 minutes. The mean X-clamp time was 14±2.5 minutes and the patient stayed in the intensive care unit for an average of 14±2 hours. The most common postoperative complication was bleeding (n=8). No cranial nerve damage was observed. There was no procedural death. Patients were discharged within an average of 4 days.
 Conclusion: Regional anesthesia can be safely performed for CEA. Considering patient preference and compliance, regional anesthesia is the first option for CEA operations in our routine.
 Keywords: carotid artery stenosis, carotid endarterectomy, regional anesthesia

Regional Anesthesia for Carotid Endarterectomy in Patients with Acute Ischemic Stroke (Pilot Study)

Objective. The aim of this study is to assess the safety of the use of regional anesthesia for performing carotid endarterectomy (CEA) in patients in the acute phase of ischemic stroke.Material and methods. The study included 66 patients in the acute phase of ischemic stroke (atherothrom-botic subtype according to the TOAST classification) who underwent carotid endarterectomy. The inclusion criteria for the study were as follows: acute phase of atherothrombotic ischemic stroke (first 28 days), ipsilateral symptomatic ≥ 50% stenosis of the internal carotid artery, 1-4 points neurological deficit according to the modified Rankin Scale (mRS), 1-13 points neurological deficit according to the National Institutes of Health Stroke Scale (NIHSS), size of the cerebral ischemic lesion ≤ 4 cm. This single-center prospective cohort study compared two anesthetic approaches, regional anesthesia (RA, 46 patients) and general anesthesia (GA, 20 patients). The RA techniques included ultrasound-guided superficial and deep cervical plexus blocks on the side of the surgery.Results. The study found no significant differences in the baseline patient characteristics, surgery techniques and clinical outcomes between the groups. There were no neurological or cardiovascular toxic reactions to the local anesthetics. Conversions from RA to GA were not performed. In the RA group, recurrent ipsilateral ischemic strokes, myocardial infarctions, wound hemorrhagic complications and lethal outcomes did not occur.Conclusion. This pilot study has demonstrated the safety of RA for performing CEA in patients in the acute phase of ischemic stroke. RA provides adequate neuromonitoring and timely intraoperative recognition of «new» ischemic complications. To compare the efficacy of RA and GA for performing CEA in patients with acute ischemic stroke, large randomized controlled trials are needed.

Regional Anesthesia is Underutilized for Carotid Endarterectomy Despite Improved Perioperative Outcomes Compared with General Anesthesia

The choice of anesthetic for carotid endarterectomy (CEA) continues to be controversial. Recent literature suggests improved outcomes with the use of regional anesthesia (RA) compared with general anesthesia (GA). The objective of this study was to examine the utilization and outcomes of RA for CEA using a national database. The targeted CEA files of the American College of Surgeons' National Surgical Quality Improvement Program (2011-2017) were reviewed. Patients were stratified based on anesthesia type into RA and GA, and patients' characteristics were compared between the 2 groups. The outcomes of CEA under GA and RA were compared after 2:1 propensity matching. There were 26,206 CEAs, and 14% (n=3,664) were performed under RA, with no change in relative utilization during the study period (P=0.557). Patients treated under RA were more likely to be older than 65 years (80.6% vs. 75.8%; P<0.001) and White (90.8% vs. 83.5%; P<0.001) but less likely to have diabetes (28.2% vs. 31.2%; P=0.001), chronic obstructive pulmonary disease (10.2% vs. 10.5%; P<0.001), and heart failure (1.0% vs. 1.5%; P=0.02) and be symptomatic (37.4% vs. 42.7%; P<0.001). After matching, there was no significant difference in baseline characteristics between the 2 groups. Patients undergoing RA were less likely to experience the combined end point of stroke, myocardial infarction, or mortality compared with GA. GA patients were more likely to have longer operating time and hospital length of stay. CEA performed under RA is associated with improved outcomes compared with GA. RA is underutilized in carotid surgery, and strategies to optimize its use are needed.

Increased resource utilization and overall morbidity are associated with general versus regional anesthesia for carotid endarterectomy in data collected by the Michigan Surgical Quality Collaborative

ObjectiveAdvocates for performing carotid endarterectomy (CEA) under regional anesthesia (RA) cite reduction in hemodynamic instability and the ability for neurologic monitoring, but many still prefer general anesthesia (GA) as benefits of RA have not been clearly demonstrated, reliable RA may not be available in all centers, and a certain amount of movement by the patient during the procedure may not be uniformly tolerated. We evaluated the association of anesthesia type and perioperative morbidity and mortality as well as resource utilization in patients undergoing CEA using the Michigan Surgical Quality Collaborative (MSQC) database. MethodsBetween 2012 and 2014, 4558 patients underwent CEA among the MSQC participating hospitals. Of these patients, 4008 underwent CEA under GA and 550 underwent CEA under RA. Data points were collected for each procedure, and a review of 30-day perioperative outcomes was conducted using the χ2 test. Propensity score regression adjusted for case mix preoperative conditions as fixed effects, and a mixed model adjusted for site as a random effect. ResultsThe two groups were similar in gender and incidence of hypertension, diabetes, congestive heart failure, and smoking history. The RA group tended to be of better functional status. After GA, there was a greater than twofold higher percentage of any morbidity (8.7% vs 4.2%). Further analysis demonstrated that patients undergoing GA had higher unadjusted rates for mortality (1.0% vs 0.0%), unplanned intubations (2.1% vs 0.6%), pneumonia (1.3% vs 0.0%), sepsis (0.8% vs 0.0%), and readmissions (9.2% vs 6.1%). Adjusting for case mix and random effect, there was statistically significantly higher overall morbidity (P = .0002), unplanned intubation (P = .0196), extended length of stay (P = .0007), emergency department visits (P = .0379), and readmissions (P = .0149) in the GA group. There was no statistically significant difference in incidence of myocardial infarction or cerebrovascular accident. ConclusionsBased on this analysis from the MSQC database, there is an associated increased morbidity and resource utilization with GA vs RA for CEA. This has implications for enterprise resource planning initiatives and the CEA value proposition in general, which is of special interest to both hospitals and payers.

Increased Overall Morbidity of General Versus Regional Anesthesia for Carotid Endarterectomy: Results From the Michigan Surgical Quality Collaborative

Increased Overall Morbidity of General Versus Regional Anesthesia for Carotid Endarterectomy: Results From the Michigan Surgical Quality Collaborative

A Cost Analysis of Regional Versus General Anesthesia for Carotid Endarterectomy

Medical care in the United States has evolved into a more cost-conscious value-based health care system that necessitates a comparison of costs when there are alternative interventions considered to be acceptable in the treatment of a disease. This study compares the cost differences between regional anesthesia (RA) and general anesthesia (GA) for carotid endarterectomy (CEA). Data from 346 consecutive patients who underwent CEA between January 2012 and September 2014 were retrospectively reviewed for the type of anesthesia used, outcomes data, and cost variables. Overall hospital day costs were compared between RA and GA. Medians and interquartile ranges were compared using Wilcoxon-Mann-Whitney test. A P<0.05 was considered statistically significant using 2-sided tests. Median overall costs for GA were significantly higher than median costs for RA (medians [with interquartile ranges], $10,140 [$7,158-$12,658] versus $7,122 [$5,072-$8,511], P<0.001). Median total operative time for GA was significantly longer than median time for RA (168 [144-188] versus 134 [115-147] min, P<0.001). Median in-hospital length of stay (LOS) for GA was significantly longer compared with RA (2.0 vs 1.2days, P<0.001). Patients who received GA were also more likely to be admitted to the intensive care unit. Decreased cost, operating room expenses, postoperative resources, and overall LOS were observed for individuals who underwent RA for CEA as compared with GA. In summary, RA is more cost-effective and should be the optimal choice when clinically appropriate.

Anesthetic type and risk of myocardial infarction after carotid endarterectomy in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST)

Carotid endarterectomy (CEA) is usually performed under general anesthesia (GA), although some advocate regional anesthesia (RA) to reduce hemodynamic instability and allow neurologic monitoring and selective shunting. RA does not reduce risk of periprocedural stroke or death, although some series show a reduction in myocardial infarction (MI). We investigated the association of anesthesia type and periprocedural MI among patients receiving GA or RA for CEA and patients undergoing carotid artery stenting (CAS) in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Between 2000 and 2008, 1151 patients underwent CEA (anesthetic type available for 1149 patients), and 1123 patients underwent CAS ≤30days of randomization in CREST. CEA patients were categorized by anesthetic type (GA vs RA). CREST defined protocol MI as chest pain or electrocardiogram change plus biomarker evidence of MI, and total MI was defined as protocol MI plus biomarker-positive (+)-only MI. The incidence of protocol MI and total MI in patients undergoing CEA under GA and RA were compared with those undergoing CAS. Other study end points were similarly compared. Differences in baseline characteristics and periprocedural events were evaluated among the three groups. Logistic regression, adjusting for age and symptomatic status, was used to assess group differences. The three groups had similar demographic risk factors, except for prevalence of symptomatic carotid stenosis, which was lowest in the CEA-RA group (P= .03). Of the 111 patients in the CEA-RA group, no protocol MIs occurred and only two biomarker+-only MIs, for an overall incidence of 1.8%, similar to the 1.7% overall incidence in patients undergoing CAS. In contrast, the combined incidence of protocol and biomarker+-only MIs in the 1038 patients in the CEA-GA group was significantly higher at 3.4% (P= .04), twice the risk of protocol MI and biomarker+-only MI compared with those undergoing CAS (odds ratio [OR], 2.01; 95% confidence interval [CI], 1.14-3.54). Direct comparison of the MI incidence between CEA-RA and CEA-GA showed no statistical difference. Patients undergoing CEA-GA had lower odds of a periprocedural stroke (OR, 0.48; 95% CI, 0.28-0.79) and stroke or death (OR, 0.46; 95% CI, 0.27-0.76) compared with those undergoing CAS but were not significantly different from those undergoing CEA-RA. Patients in CREST undergoing CEA-RA had a similar risk of periprocedural MI as those undergoing CAS, whereas the risk for CEA-GA was twice that compared with patients undergoing CAS. Nevertheless, because periprocedural MI is one of the few variables favoring CAS over CEA and has been associated with decreased long-term survival, RA should be seriously considered for patients undergoing CEA.

Advantages of regional anesthesia for carotid endarterectomy

At 190 patients with carotid endarterectomy the relative assessment of total intravenous anaesthesia with use propofol, penetrating blockage of a cervical plexus and inhalation sevofluran is made. Cerebral circulation parametres, markers of cerebral damage, a state of the highest mental functions were investigated. It is shown that for each kind of anaesthesia specific changes of parametres of the cerebral blood-groove, defining level neuronal damages that affects on a state of number and character of postoperative complications are characteristic.

Examination of regional anesthesia for carotid endarterectomy

Carotid endarterectomy is the most effective treatment for reducing the risk of stroke in patients with significant carotid stenosis. Few studies have focused on the failure rate of regional anesthesia. Data of all patients undergoing carotid endarterectomy (June 2009 to December 2014) in a single center were collected. Combined deep and superficial cervical plexus block or superficial plexus block alone was used according to the attending anesthesiologist's choice and the patient's characteristics (eg, dual antiplatelet or anticoagulation therapy). Intraoperative remifentanil (0.025-0.05 μg/kg/min) was administered to maintain an adequate level of comfort, responsiveness, and cooperation. General anesthesia was planned only in the case of major contraindications or the patient's refusal of locoregional anesthesia. The primary end point of our study was the incidence of intraoperative conversion from locoregional to general anesthesia. A total of 2463 carotid endarterectomies were included in the analysis. Regional anesthesia was initially chosen in 2439 patients, whereas 24 patients received planned general anesthesia. In seven cases, regional anesthesia was converted to general anesthesia because of severe agitation of the patient (before clamping in four cases, after carotid clamping in two cases, and after declamping in one case). A shunt was used in 302 patients (12.3%) because of neurologic deterioration at the carotid clamping test. Intraoperative complications were emergent repeated surgical procedures in 13 cases (0.53%) because of acute neurologic deterioration, 1 intraoperative acute myocardial infarction (0.04%), and 3 cases (0.04%) of hemodynamically relevant supraventricular tachyarrhythmia. No intraoperative death occurred. In-hospital mortality was 0.12% (three patients). Major stroke occurred in 23 patients (0.93%); minor stroke occurred in 16 patients (0.65%). The combined stroke and death rate was 1.62% (40 patients). In our practice, carotid endarterectomy under regional anesthesia is safe and associated with a very low rate of conversion to general anesthesia.

Ultrasound-guided regional anesthesia for carotid endarterectomy induces early hemodynamic and stress hormone changes

Locoregional anesthesia is an effective method for evaluating cerebral function during carotid endarterectomy (CEA). Landmark-guided regional anesthesia (RA) is currently used for CEA and can provoke substantial perioperative hypertension. Ultrasound-guided RA (US-RA) is a new method for performing RA in CEA; however, the effect on sympathetic activity and blood pressure is uncertain. This study assessed early sympathetic activity during CEA in US-RA compared with general anesthesia (GA). Patients were prospectively randomized to receive US-RA (n = 32) or GA (n = 28) for CEA. The primary end point was the change in systolic arterial blood pressure after induction of anesthesia (just before starting surgery) comparing US-RA with GA. We also recorded heart rate and analyzed concentrations of plasma blood hormones, including cortisol, metanephrine, and normetanephrine at five different times. Creatinine kinase, troponin I, and N-terminal pro-B-type natriuretic peptide were analyzed to detect potential changes in cardiac biomarkers during the procedure. Systolic arterial blood pressure (mean ± standard deviation) increased significantly in US-RA patients compared with GA patients even before surgery was initiated (180 ± 26 mm Hg vs 109 ± 24 mm Hg; P < .001), then remained elevated during the entire surgery and returned to baseline values 1 hour after admission to the postoperative anesthesia care unit. Heart rate (US-RA: 78 ± 16 beats/min, GA: 52 ± 12 beats/min; P < .001) and cortisol levels (US-RA: 155 ± 97 μg/L, GA: 99 ± 43 μg/L; P = .006) were also significantly higher in the US-RA group after induction of anesthesia. Other values did not differ. The US-RA technique for CEA induces temporary intraoperative hypertension and an increase in stress hormone levels. Nevertheless, US-RA is a feasible, effective, and safe form of locoregional for CEA that enables targeted placement of low volumes of local anesthesia under direct visualization.

Sonoanatomy of the “Cervical Nerves Pathway”. Recommendations for ultrasound-guided regional anaesthesia for carotid endarterectomy

Sonoanatomy of the “Cervical Nerves Pathway”. Recommendations for ultrasound-guided regional anaesthesia for carotid endarterectomy

Regional anesthesia for carotid endarterectomy decreases incidence of shunt placement

Regional anesthesia for carotid endarterectomy decreases incidence of shunt placement

Increased Oxygen Administration Improves Cerebral Oxygenation in Patients Undergoing Awake Carotid Surgery

During regional anesthesia for carotid endarterectomy (CEA), 10% to 15% of patients develop signs of cerebral hypoxia after cross-clamping, manifested as changes in speech, cerebration or contralateral motor power. Reversal of such neurological deficits using administration of 100% O2 has been described. We used near-infrared cerebral oximetry to assess whether 100% O2 reliably improves regional cerebral oxygenation (rSO2) during carotid cross-clamping. Sixteen patients undergoing awake CEA were studied. Bilateral rSO2 optodes were applied before the initiation of sedation and the conduct of the regional blockade. Patients received 28% oxygen by Venturi facemask. Perioperative blood pressure was maintained at or within 10% above the patient's normal limits during carotid cross-clamping. After cross-clamping, 100% O2 was administered for 5 min by a close-fitting anesthetic facemask. The O2 mask was then removed and the patient breathed room air. The effects on rSO2 readings and arterial blood gases were observed after each intervention. Data were analyzed for 15 patients. Ipsilateral rSO2 values decreased by 7.4% +/- 5% after carotid cross-clamping. Administration of 100% O2 resulted in an increase in ipsilateral rSO2 in all patients of 6.9% +/- 3.3% (range, 1%-12%) (paired t-test, P < 0.001) over the cross-clamped value while receiving 28% O2. Hemodynamic variables and arterial PaCO2 values were unaltered. With the carotid cross-clamped, ipsilateral rSO2 was reliably increased by the administration of 100% O(2) compared with 28% O2. The etiology of this increase is unclear, but may relate to the associated increase in O2 content of the blood or to an improvement in cerebral blood flow. Thus administration of 100% O2 during carotid cross-clamping may be beneficial for all patients undergoing CEA.

Regional Anesthesia for Carotid Surgery: Less Intraoperative Hypotension and Vasopressor Requirement

Regional anesthesia (RA) is the gold standard of neuromonitoring during carotid endarterectomy (CEA). Recent data show that RA for CEA is associated with fewer postoperative complications. The aim of the present study was to assess hemodynamic stability and vasoactive drug use for CEA performed under RA versus general anesthesia (GA). All patients undergoing CEA from January 2005 to January 2006 were identified from our prospective database. Electronic and paper charts were reviewed. Intraoperative monitoring data were reviewed retrospectively. Hypotension was defined as systolic blood pressure (SBP) <100 mm Hg and deemed prolonged if it lasted more than 10 min. Hypertension was defined as SBP >160 mm Hg. BP variation was defined as the difference between the highest and lowest SBP, and bradycardia as heart rate (HR) below 60. The data were expressed as means +/- standard deviation. Seventy-two consecutive patients underwent CEA: 25 under RA and 47 under GA. There was no difference in preoperative HR and BP. Most patients had symptomatic severe carotid stenosis (80% in RA vs. 85% in GA, nonsignificant). Intraoperatively, RA was associated with less BP variation (60 +/- 27 vs. 78 +/- 22 mm Hg, p = 0.005), bradycardia (5% vs. 63%, p < 0.001), hypotension (20% vs. 70%, p < 0.01), and prolonged hypotension (0% vs. 23%, p = 0.009) and more hypertension (80% vs. 47%, p = 0.007). Vasopressor requirements were less frequent under RA (20% vs. 77%, p < 0.001). There was no significant difference between groups in hypotension or hypertension episodes seen in the postoperative recovery room. RA was associated with less hypotension and less vasopressor used during CEA compared to GA. The improved hemodynamic stability may account for the lower incidence of complications after CEA.

Regarding “hemodynamic benefits of regional anesthesia for carotid endarterectomy”

Regarding “hemodynamic benefits of regional anesthesia for carotid endarterectomy”

Hemodynamic benefits of regional anesthesia for carotid endarterectomy

Objective: The objective of this study was to define differences in perioperative hemodynamics and associated outcomes in patients who undergo carotid endarterectomy (CEA) with regional and general anesthesia. Methods: All the patients who underwent CEA during a 25-month period were reviewed, with a comparison of those who underwent operation with cervical block anesthesia (CB) with those who underwent operation with general anesthetic (GA). Baseline intraoperative and postoperative blood pressure and heart rate were recorded, and deviation from initial values was calculated. The administration of vasoactive medications was assessed. Operative time, intensive care unit admission, postoperative length of stay, and cardiac/neurologic morbidity were recorded. Results: From October 16, 1998, to December 1, 2000, 550 nonemergent CEAs were performed in 527 patients (226 with CB and 324 with GA). The patients in both groups were similar in age, presentation, and associated comorbidities. Although baseline blood pressure and heart rates were similar in both groups, those patients who underwent operation with GA had significantly greater intraoperative and postoperative hemodynamic variability and received more vasoactive medications during surgery (87% versus 51%; P <.001) and in the recovery room (36% versus 21%; P =.0009). Major postoperative blood pressure derangements were more common in the GA group (18% versus 10%; P <.05). Patients who underwent operation with GA more frequently needed intensive care unit admission (16% versus 7%; P =.01) and had more frequent delays in discharge (20% versus 11%; P =.008; postoperative length of stay, 2.1 versus 1.6 days; P =.01). Although no difference was seen in neurologic morbidity rates between groups (combined major stroke/death rate, 1.8%), the major cardiac morbidity rate was noted to be lower in the CB group (1% versus 4%; P =.05). The total in-room time was shorter in the CB group (108 versus 122 minutes; P <.001). Conclusion: CEA performed with CB is associated with significantly less perioperative hemodynamic instability than with GA. This results in fewer major adverse cardiac events. Ultimately, decreased critical care resource use is realized as is a shortened length of stay. (J Vasc Surg 2002;35:333-9.)

Remifentanil conscious sedation during regional anaesthesia for carotid endarterectomy: rationale and safety.

to prospectively evaluate the safety and efficacy of remifentanil during regional anaesthesia for carotid endarterectomy. twenty-eight consecutive patients underwent carotid endarterectomy with combined superficial and deep cervical plexus block supplemented with continuous intravenous 0.04 microg.kg(-1).min(-1)remifentanil infusion. Depth of sedation was monitored using the Observer's Assessment of Alertness/Sedation Scale (OAA/S). The degree of pain, discomfort and anxiety was self-assessed by the patients using a horizontal visual analogue scale. all patients experienced adequate comfort and analgesia. No local anaesthetic supplementation was necessary. No patient had a OAA/S score lower than 4 (with 5=awake/alert to 1=asleep). Respiratory depression did not occur. Selective shunting was required in four cases. No patient was converted to general anaesthesia. There were no permanent neurological deficits, cardiopulmonary complications or deaths. remifentanil as a supplement to regional anaesthesia for carotid endarterectomy, provides comfort and analgesia without hampering mental status evaluation.

Complications from Regional Anaesthesia for Carotid Endarterectomy

Complications from Regional Anaesthesia for Carotid Endarterectomy