Utilization and Outcomes of Local Anesthesia and Peripheral Nerve Block for Hybrid Lower Extremity Revascularization

Abstract

Purpose: To investigate the utilization of local anesthesia or peripheral nerve block with monitored anesthesia care (LPMAC) and its impact on the perioperative outcomes of hybrid lower extremity revascularization (LER) compared with general anesthesia (GA). Materials and Methods: A search of the ACS-NSQIP database between 2005 and 2017 identified 9430 patients who underwent hybrid LER for peripheral artery disease. Excluding 449 ineligible cases left 8981 hybrid LER patients for analysis. The patients were dichotomized based on the anesthetic technique: 8631 (96.1%) GA and 350 (3.9%) LPMAC. The GA patients were matched 3:1 based on propensity scores to patients in the LPMAC group based on gender, age, race, functional status, transfer status, chronic obstructive pulmonary disease (COPD), dialysis status, American Society of Anesthesiologists (ASA) class, emergent surgery, preoperative sepsis, indication, and type of open and endovascular procedure. Outcomes including complications, mortality, procedure time, and hospital length of stay were compared between the matched groups (801 GA vs 267 LPMAC). Results: Comparing the unmatched groups, those treated under LPMAC were older (72.7±9 vs 68±8.4 years, p<0.001) and had higher rates of COPD (24.3% vs 17%, p=0.001), dialysis dependence (8.1% vs 4.2%, p=0.002), preoperative sepsis (6.6% vs 4.2%, p=0.029), and ASA class ≥IV (29.1% vs 24.1%, p=0.036) than in the unmatched GA cohort. In the matched comparison, LPMAC was associated with lower overall morbidity (25.5% vs 32.3%, p=0.042) and shorter operating time (202.7±98 vs 217.7±102 minutes, p=0.034) compared with GA. The rate of myocardial infarction was lower (1.1% vs 2.4%) and ventilator use for >48 hours was less frequent (0.4% vs 2.6%) for LPMAC patients, though statistical significance was not reached. There was no difference in mortality or hospital length of stay. Conclusion: LPMAC is an infrequent anesthetic technique for hybrid LER and is primarily used for patients with a high burden of comorbidities. LPMAC is associated with reduced overall morbidity and operating time. Further studies are needed to identify which patients undergoing hybrid LER benefit most from LPMAC.

Association of anaesthesia technique with 30-day primary graft patency after open lower limb revascularization: retrospective cohort study

“…In terms of secondary outcomes, no association between regional technique and outcomes was found except for decreased non-home discharge and increased LOS; however, the differences were small, and these exploratory results should be interpreted with caution in the context of small sample size and multiple testing 25 . The difference in LOS may be related to the sicker population in the RA group, and the small magnitude of difference aligns with previous literature of small to no differences in LOS 19 , 20 , 24 . While RA was associated with decreased odds of non-home discharge, this may be related to the more complex grafts and surgeries in the GA group, though the mechanism remains to be elucidated given the lack of difference amongst rates of patency, reintervention, morbidity, and mortality outcomes in the current cohort.…”

“…The literature has shown mixed results regarding the superiority of RA over GA for morbidity and mortality 1 , 5 , 19 , 20 , 24 . In terms of secondary outcomes, no association between regional technique and outcomes was found except for decreased non-home discharge and increased LOS; however, the differences were small, and these exploratory results should be interpreted with caution in the context of small sample size and multiple testing 25 .…”

Racial Disparities in the Use of Peripheral Nerve Blocks for Postoperative Analgesia After Total Mastectomy: A Retrospective Cohort Study

“…Previous studies have found varying results related to the impact of PNBs on major complications, but most were in orthopedic and vascular surgery patients. [29][30][31] We were unable to analyze whether PNBs enhance total mastectomy patients' quality of recovery because of a lack of data in NSQIP. Previous studies suggest that PNBs have a significant positive impact on quality of recovery.…”

Hybrid Vascular Approach Reduces the Intensive Care Unit Stay in Patients With Chronically Threatening Limb Ischemia and Multilevel Atherosclerotic Lesions

“…A review of the literature shows that there is a lack of objective data regarding the length of stay in the intensive care unit (ICU) of patients treated with hybrid revascularization for chronic limb-threatening ischemia and multilevel atherosclerotic lesions compared to the classical method of surgical revascularization [20][21][22][23][24][25].…”