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

Lumas, Shunella; Hsiang, Walter; Akhtar, Shamsuddin; Chaar, Cassius Iyad Ochoa

doi:10.1016/j.avsg.2020.11.035

Cited by 11 publications

(9 citation statements)

References 16 publications

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“…The GALA Trial Collaborative Group (2008) demonstrated no difference in primary outcome (a composite of 30-day stroke, myocardial infarction (MI), or death) between the two anesthetic techniques in a landmark randomized controlled trial 3 . While these results have been replicated by some studies 12 , 15 – 18 , others have demonstrated a clinical benefit with regional anesthesia 10 , 11 , 19 – 24 . Several studies found an increased risk for postoperative MI with general anesthesia 19 – 21 .…”

Section: Introductionmentioning

confidence: 84%

Effect of regional versus general anesthesia on thirty-day outcomes following carotid endarterectomy: a cohort study

Kline

Kothandaraman

Knio

et al. 2023

International Journal of Surgery

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Background: The effect of regional versus general anesthesia on carotid endarterectomy outcomes is debated. This study assesses the effect of anesthetic technique on major morbidity and mortality and additional secondary endpoints following carotid endarterectomy. Materials and methods: This was a retrospective propensity-matched-cohort analysis investigating elective carotid endarterectomy patients in the 2015–2019 American College of Surgeons National Surgical Quality Improvement Program (n=37 204). The primary endpoint was 30-day mortality and major morbidity, defined as stroke, myocardial infarction, or death. Secondary endpoints included minor morbidity, bleeding events, healthcare resource utilization, and length of hospital stay. Univariate, multivariable, and survival analyses were applied. Results: The 1 : 1 propensity-matched-cohort included 8304 patients (4152 in each group). Regional anesthesia was associated with similar incidences of major morbidity and mortality [odds ratio (OR), 0.81 (95% CI, 0.61–1.09); P = 0.162] and unplanned resource utilization [OR, 0.93 (95% CI, 0.78–1.11); P = 0.443], but lower incidences of minor morbidity [OR, 0.60 (95% CI, 0.44–0.81); P < 0.001] and bleeding events [OR, 0.49 (95% CI, 0.30–0.78); P = 0.002], and a shorter length of hospital stay [1.4 vs. 1.6 days; mean difference, -0.16 days (95% CI, -0.25 to -0.07); P < 0.001]. On multivariable analysis, regional anesthesia remained independently predictive of minor morbidity [adjusted odds ratio (AOR), 0.58 (95% CI, 0.42–0.79); P = 0.001] and bleeding events [AOR, 0.49 (95% CI, 0.30–0.77); P = 0.003]. Significance was maintained on survival analysis for these two endpoints. A mortality benefit was observed on univariate [OR, 0.50 (95% CI, 0.25–1.00); P = 0.045], multivariable [AOR, 0.49 (95% CI, 0.24–0.96); P = 0.043], and survival analysis (P = 0.045). Conclusions: Carotid endarterectomy patients receiving regional anesthesia experience favorable outcomes compared to propensity-matched general anesthesia controls.

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Section: Introductionmentioning

confidence: 84%

Effect of regional versus general anesthesia on thirty-day outcomes following carotid endarterectomy: a cohort study

Kline

Kothandaraman

Knio

et al. 2023

International Journal of Surgery

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“…The GALA study did not show a difference in postoperative stroke, myocardial infarction, or death when CEA was performed with general or regional anesthesia; however, 1-year survival data suggested fewer subsequent events in the regional anesthesia patient group [ 24 ]. A large study using the ASC-NSQIP database revealed CEA performed under regional anesthesia is not only associated with reduced perioperative morbidity and mortality, it is also associated with shorter operative time and hospital length of stay [ 25 ]. This result is supported by several other studies mentioned in this review [ 23 ].…”

Section: Discussionmentioning

confidence: 99%

Case of Amaurosis Fugax in the Setting of a Persistent Primitive Hypoglossal Artery Requiring Carotid Endarterectomy with Regional Anesthesia

et al. 2023

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Congenital defects/diseases Background:A persistent primitive hypoglossal artery (PPHA) is a rare congenital anomaly leading to persistent carotid-basilar anastomosis. This is a report of an 83-year-old man with a PPHA presenting with amaurosis fugax of the left eye requiring carotid endarterectomy under regional anesthesia. Case Report:An 83-year-old man presented with 2 weeks of intermittent self-resolving visual disturbances, followed by an episode of left eye amaurosis fugax. The patient had been referred to the hospital for further investigation of symptoms 1 day following the amaurosis fugax event. Carotid Doppler ultrasound demonstrated a greater than 90% stenosis of the left internal carotid artery. Computed tomography carotid and Circle of Willis angiography confirmed a mixed, ulcerated plaque and revealed a persistent left hypoglossal artery originating from the left internal carotid artery and continuing as the basilar artery. On day 3 of admission, left carotid endarterectomy was performed under conscious sedation and regional anesthesia to permit continuous monitoring of neurological status and avoid the need for intraoperative shunting. "Permissive hypertension" by targeting a systolic blood pressure of 190 to 200 mmHg was sought for the duration of clamp time. There was no deterioration of neurological function during clamping of the carotid vessels. The patient recovered well and was discharged 2 days after surgery, with no residual neurology. Conclusions:This report has presented a rare case of PPHA to highlight awareness of this congenital vascular anomaly when undertaking carotid endarterectomy.

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“…A recent Cochrane meta-analysis has also shown equivalence between the two methods [16]. Multiple, smaller studies have shown that regional anesthesia is associated with decreased rates of complications, shorter hospital stays, and lower costs compared to general anesthesia [7][8][9][10][11][12][13][14][15].…”

Section: Discussionmentioning

confidence: 99%

“…Carotid endarterectomy may be performed under either regional or general anesthesia. Regional anesthesia allows for at least equivalent results in patients who are unable to tolerate general anesthesia [5][6][7] and may be associated with shorter hospital length of stay, reduced anesthesia and operative time, decreased complications including pneumonia and cranial nerve injury, and lower costs [8][9][10][11][12][13][14][15]. In this technical paper we review the importance of patient selection, anatomical variations, and operative nuances including cervical block for performing CEA under regional anesthesia.…”

Section: Introductionmentioning

confidence: 99%

Carotid Endarterectomy using Regional Anesthesia: Technique and Considerations.

Padmanaban

Caldwell

Milne

et al. 2023

Preprint

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BACKGROUND Carotid endarterectomy (CEA) is one of the most effective neurosurgical operations in minimizing stroke risk in both symptomatic and asymptomatic patients with carotid stenosis. Awake CEA with regional anesthesia may decrease both perioperative complications and length of hospital stay. The awake carotid operation is not often described in published literature. OBJECTIVE To describe our experience with carotid endarterectomy 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. METHODS Carotid endarterectomy using regional anesthesia is described in detail. RESULTS Successful use of regional anesthesia during carotid endarterectomy without complication. CONCLUSION 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.

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

Cited by 11 publications

References 16 publications

Effect of regional versus general anesthesia on thirty-day outcomes following carotid endarterectomy: a cohort study

Effect of regional versus general anesthesia on thirty-day outcomes following carotid endarterectomy: a cohort study

Case of Amaurosis Fugax in the Setting of a Persistent Primitive Hypoglossal Artery Requiring Carotid Endarterectomy with Regional Anesthesia

Carotid Endarterectomy using Regional Anesthesia: Technique and Considerations.

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