Simultaneous Bilateral Carotid Endarterectomy under Cervical Plexus Blockade

Abstract

In patients with severe carotid artery stenosis who developed transient ischemic attack, carotid endarterectomy is one of the most effective treatments. In particular, in patients with contralateral carotid artery lesions, there is a risk of serious neurologic complications during the intra-operative period. Experienced staff can perform simultaneous bilateral carotid endarterectomy safely in carefully selected patients. The advantages of regional anaesthesia in carotid endarterectomy are evaluation of intra-operative neurological condition and defining correct indications for shunt usage. It is a cheap, reliable and easy method that reduces the length of stay in the intensive care unit and in the hospital and may influence the overall cost of care. However, it is important to make dose adjustments to avoid potential complications of nerve involvement during bilateral procedure. In this case report, we share our experiences regarding bilateral carotid endarterectomy under cervical plexus blockade. Keywords:Cervical plexus, nerve block, carotid endarterectomy, carotid stenosis Geçici iskemik atak geçirmiş ve ciddi karotis arter darlığı bulunan hastalarda halen karotis endarterektomisi en etkin tedavi yöntem-lerinden biridir. Özellikle karşı taraf karotis arterinde de lezyonu bulunan hastalar intraoperatif ciddi nörolojik komplikasyon riski altındadır. Eş zamanlı bilateral karotis endarterektomileri deneyimli ekip ve uygun hasta seçimiyle güvenle yapılabilmektedir. Karotis endarterektomilerinde rejyonal anestezinin avantajları intraoperatif nörolojik durumu değerlendirebilme ve doğru şant endikasyonunu koyabilmeye olanak sağlamasıdır. Ucuz, güvenilir ve kolay bir yöntem olduğu kadar hastanede ve yoğun bakımda kalış süresini kısaltarak hastane maliyetini de düşürür. Özellikle bilateral uygulamalar sırasında sinir tutulumlarının olası komplikasyonlarından kaçınmak için doz ayarlaması yapılması önemlidir. Bu olgu sunumunda servikal pleksus blokajı ile yapılan bilateral karotis endarterektomisi deneyimimizi paylaştık. 367 Giriş S erebrovasküler hastalıklar, tüm dünyada, kanser ve kalp hastalıklarından sonra en çok ölüme neden olan hastalıklar-dır. Karotis arterlerin darlığı, serebrovasküler hastalıkların en önemli nedenlerinden biri olup tüm inmelerin %20 -25'inden sorumludur (1). Karotis endarterektomisi (KEA) %70'in üzerinde darlığı olan semptomatik hastalarda altın standart tedavi şekli iken, asemptomatik hasta grubu için tartışma halen devam etmektedir (2). KEA yüksek dereceli internal karotis arter darlığı olan semptomatik hastalarda inme riskini azaltır. Bilateral karotis arter stenozu sık olmakla beraber, aynı seansta endarterektomi yapılması fazla tercih edilmemektedir. Yaygın olarak basamaklı endarterektomi yaklaşımı kabul görmektedir. Bununla birlikte özellikle iki taraflı %90 ve üzeri darlığı olan, ülsere, kalsifik ve emboli riski yüksek plakları bulunan hastalarda, basamaklı tedavi arasındaki sürede yüksek emboli riski nedeniyle aynı seansta bilateral endarterektomi tercih edilmektedir.Karotis endarterekto...

Carotid Endarterectomy in Awake Patient: Review Article

“…• Control of ventilation (tight control of arterial carbon dioxide concentration) (13)(14)(15)(16)(17) • Cerebral protection afforded by volatile anaethesia (especially during the cross-clamp) (13,18,15,(19)(20)(21) • Airway security (anaesthetist preference) (13,22,15,19,17) • Excellent and comfortable operation conditions (especially in patients with high carotid bifurcation) (14,17,(19)(20)(21) • Prevent myocardial ischemia (19) • Less stressful than a regional procedure (14,20) • Prevent patients from coughing and straining (19) • Possibility of inducing hypothermia if required (15) Disadvantages of GA are:…”

“…• GA necessitates shunt insertion more commonly than RA techniques (14,15,23,27) • Requires brain monitoring (stump pressure, somatosensory evoked potential, transcranial Doppler, electroencephalogram and near-infrared spectroscopy, juguler venous oxygen,cerebral oximetry) (3,7,9,24,30) . These methods shows poor sensitivity and specificity according to awake patient, in terms of requirement for shunt placement (15,24) • Anaesthetic-induced circulatuar depression is associated with labile blood pressure (3) and necessitates greater vasopressor support (To ensure adequate cerebral perfusion pressure during carotid cross-clemping) (14,15,25,26,) • Higher incidence in postoperative neurocognitive dysfunction (15,17) Advantages of regional anesthesia are:…”

“…• Awake patient is the gold standart cerebral function monitoring (14,15,17,20,21) • Reduce cardiac and respiratory related morbidity (15,16,18,20) • Lower shunt insertion rate (14,15,17,19,21,24) • Shorten hospital stay (14,15,17,19,21,24) • Lower cost (14,15,18,21) • Improves outcomes after surgery (better postoperative analgesia, reduce blood loss, lower risk of tromboembolic events) (15,18,20,22) • Safer (14) • Safe method to identify the patients at risk for crossclamp intolerance (1,3,12) • Hemodynamic stability (14,17,18,21,22,24,27) • Preserved cerebral autoregulation (14,16,18,24,25) • Reduce vasopressor requirement (25) • Reduces operative time (24) Disadvantages of regional anest...…”

“…• Procedural complications (diaphragmatic and vocal cord paralysis, neural injuries, epidural, subaracnoid or intravascular injection of local anaesthetics) (15) • Urgent conversion of regional anesthesia into general anesthesia (15,16,26) • Anxiety during the operation (14,16) Regarding complications, superficial cardiopulmonary bypass (CPB) is associated with the common adverse effects of any nerve block such as inadvertent intravascular injection of local anesthetic and local anesthetic toxicity. In addition to these effects, deep CPB increases the occurrence of complications arising from the placement of the block, including accidental intravascular injection into the vertebral artery, subdural injection resulting in subarachnoid block, large neck hematoma, bilateral recurrent laryngeal nerve palsy, and phrenic nerve palsy (28)(29)(30) .…”

“…This is largely because individual patients vary in their susceptibility to reduced cerebral blood flow. The principle advantage of LA for CEA is the ability to monitor patients with direct neurological assessment and selectively shunt if they develop neurological signs (12,14) . Indeed for those surgeons who adopt a policy of selective shunting, CEA under LA is the only method capable of predicting accurately which patients need a shunt.…”