1
|
Hansen J, Cotter E. "Combined Coronary and Carotid Disease: What to Operate on First? Or Both at the Same Time?". J Cardiothorac Vasc Anesth 2024; 38:1425-1427. [PMID: 38641467 DOI: 10.1053/j.jvca.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 04/21/2024]
Affiliation(s)
- Jennette Hansen
- Department of Anesthesiology, University of Kansas Medical Center, 3901 Rainbow Blvd MS 1034, Kansas City, KS 66160
| | - Elizabeth Cotter
- Department of Anesthesiology, University of Kansas Medical Center, 3901 Rainbow Blvd MS 1034, Kansas City, KS 66160.
| |
Collapse
|
2
|
Pereira-Macedo J, Silva AF, Duarte-Gamas L, Andrade JP, Sousa-Pinto B, Rocha-Neves J. Incidence of myocardial injury in patients submitted to carotid endarterectomy. VASA 2024; 53:13-27. [PMID: 37987782 DOI: 10.1024/0301-1526/a001101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
Myocardial injury following noncardiac surgery (MINS) is associated with higher mortality and major adverse cardiovascular event rates in the short- and long-term in patients undergoing carotid endarterectomy (CEA). However, its incidence is still unclear in this subset of patients. Therefore, this systematic review with meta-analysis aims to determine the incidence of MINS in patients undergoing CEA. Three electronic databases MEDLINE, Scopus, and Web of Science were used to search for studies assessing the occurrence of MINS in the postoperative setting of patients undergoing CEA. The incidence of MINS was pooled by random-effects meta-analysis, with sources of heterogeneity being explored by meta-regression and subgroup analysis (general anesthesia vs. regional anesthesia). Assessment of studies' quality was performed using National Heart, Lung, and Blood Institute Study Quality Assessment Tool, and Risk of Bias 2 tools. Twenty studies were included, with a total of 117,933 participants. Four of them were RCTs, while the remaining were cohort studies. All observational cohorts had an overall high risk of bias, except for Pereira Macedo et al. Three of them had repeated population, thus only data from the most recent one was considered. On the other hand, all RCT had an overall low risk of bias. In patients under regional anesthesia, the incidence of MINS in primary studies ranged between 2% and 15.3%, compared to 0-42.5% for general anesthesia. The meta-analytical incidence of MINS after CEA was of 6.3% [95% CI 2.0-10.6%], but severe heterogeneity was observed (I2=99.1%). MINS appears to be relatively common among patients undergoing CEA. The observed severe heterogeneity points to the need for further larger studies adopting consistent definitions of MINS and equivalent cut-off values.
Collapse
Affiliation(s)
- Juliana Pereira-Macedo
- Department of Surgery, Hospitalar Centre of Medio-Ave, Vila Nova de Famalicão, Portugal
- Department of Angiology and Vascular Surgery, University Hospitalar Centre of Sao Joao, Porto, Portugal
- Faculty of Medicine of University of Porto, Portugal
| | | | - Luís Duarte-Gamas
- Department of Angiology and Vascular Surgery, University Hospitalar Centre of Sao Joao, Porto, Portugal
| | - José Paulo Andrade
- Department of Biomedicine, Unity of Anatomy, Faculty of Medicine, University of Porto, Portugal
- CINTESIS@RISE - Centre for Health Technology and Services Research, Porto, Portugal
| | - Bernardo Sousa-Pinto
- CINTESIS@RISE - Centre for Health Technology and Services Research, Porto, Portugal
- MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Portugal
| | - João Rocha-Neves
- Department of Angiology and Vascular Surgery, University Hospitalar Centre of Sao Joao, Porto, Portugal
- Department of Biomedicine, Unity of Anatomy, Faculty of Medicine, University of Porto, Portugal
- Department of Physiology and Surgery, Faculty of Medicine, University of Porto, Portugal
| |
Collapse
|
3
|
Li C, Rockman C, Chang H, Patel VI, Siracuse JJ, Cayne N, Veith FJ, Torres JL, Maldonado TS, Nigalaye AA, Jacobowitz G, Garg K. Neuroprotective association of preoperative renin-angiotensin system blocking agents use in patients undergoing carotid interventions. Vascular 2023; 31:1143-1150. [PMID: 35603781 DOI: 10.1177/17085381221093900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
OBJECTIVE The optimal medical management strategy in the periprocedural period for patients undergoing carotid artery interventions is not well described. Renin-angiotensin-system blocking (RASB) agents are considered to be among the first line anti-hypertensive agents; however, their role in the perioperative period is unclear. The objective of this study was to examine the relationship between the use of RASB agents on periprocedural outcomes in patients undergoing carotid interventions-carotid endarterectomy (CEA), transfemoral carotid artery stenting (CAS), and transcervical carotid artery revascularization (TCAR). METHOD The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing CAS, CEA, and TCAR between 2003 and 2020. Patients were stratified into two groups based upon their use of RASB agents in the periprocedural period. The primary endpoint was periprocedural neurologic events (including both strokes and transient ischemic attacks (TIAs)). The secondary endpoints were peri-procedural mortality and significant cardiac events, including myocardial infarction, dysrhythmia, and congestive heart failure. RESULTS Over 150,000 patients were included in the analysis: 13,666 patients underwent TCAR, 13,811 underwent CAS, and 125,429 underwent CEA for carotid artery stenosis. Overall, 52.2% of patients were maintained on RASB agents. Among patients undergoing CEA, patients on RASB agents had a significantly lower rate of periprocedural neurologic events (1.7% versus 2.0%, p =0.001). The peri-procedural neurological event rate in the TCAR cohort was similarly reduced in those treated with RASB agents, but did not reach statistical significance (2.0% vs 2.4%, p = 0.162). Among patients undergoing CAS, there was no difference in perioperative neurologic events between the RASB treated and untreated cohorts (3.4% vs 3.2%, p = 0.234); however, the use of RASB agents was significantly associated with lower mortality (1.2% vs 1.7%, p =0.001) with CAS. The use of preoperative RAS-blocking agents did not appear to affect the overall rates of adverse cardiac events with any of the three carotid intervention types, or periprocedural mortality following CEA or TCAR. On multivariable analysis, the use of RAS-blocking agents was independently associated with lower rates of post-procedural neurologic events in patients undergoing CEA (OR 0.819, CI 0.747-0.898; p = 0.01) and TCAR (OR 0.869, CI 0.768-0.984; p = 0.026), but not in those undergoing CAS (OR 0.967, CI 0.884-1.057; p = 0.461). CONCLUSION The use of peri-procedural RASB agents was associated with a significantly decreased rate of neurologic events in patients undergoing both CEA and TCAR. This effect was not observed in patients undergoing CAS. As carotid interventions warrant absolute minimization of perioperative complications in order to provide maximum efficacy with regard to stroke protection, the potential neuro-protective effect associated with RASB agents use following CEA and TCAR warrants further examination.
Collapse
Affiliation(s)
- Chong Li
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Caron Rockman
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Heepeel Chang
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Virendra I Patel
- Division of Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, MA, USA
| | - Neal Cayne
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Frank J Veith
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Jose L Torres
- Department of Neurology, New York University Langone Health, New York, NY, USA
| | - Thomas S Maldonado
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY, USA
| | | | - Glenn Jacobowitz
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY, USA
| |
Collapse
|
4
|
Kline LA, Kothandaraman V, Knio ZO, Zuo Z. Effect of regional versus general anesthesia on thirty-day outcomes following carotid endarterectomy: a cohort study. Int J Surg 2023; 109:1291-1298. [PMID: 37057905 PMCID: PMC10389611 DOI: 10.1097/js9.0000000000000356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/13/2023] [Indexed: 04/15/2023]
Abstract
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.
Collapse
Affiliation(s)
- Leigh A. Kline
- Department of Anesthesiology, University of Virginia Health
| | | | - Ziyad O. Knio
- Department of Anesthesiology, University of Virginia Health
| | - Zhiyi Zuo
- Department of Anesthesiology, University of Virginia Health
| |
Collapse
|
5
|
Patel SH, Sundararaghavan VL, Pawlikowski AM, Albright J, Adams JM, Heidenreich MJ, Beaulieu RJ, Aziz A. Outcomes of Dexmedetomidine with Local Regional Anesthesia in Carotid Endarterectomy. Ann Vasc Surg 2023; 89:174-181. [PMID: 36229003 DOI: 10.1016/j.avsg.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/01/2022] [Accepted: 08/25/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Adequate sedation to complement regional techniques in carotid endarterectomy (CEA) can be challenging. Dexmedetomidine has both analgesic and amnesic properties and is reported to be a safe and acceptable alternative to conventional general endotracheal anesthesia (GETA). Outcomes observing dexmedetomidine in conjunction with regional anesthesia in CEA are not well described or known. OBJECTIVE Compare the immediate (during hospitalization) and short-term (within 30 days of hospitalization) postoperative outcomes in patients who underwent CEA using GETA versus local regional anesthesia (LRA) alone versus dexmedetomidine with LRA at a single institution to determine whether dexmedetomidine is a safe adjunct and if there are anesthesia advantages over LRA alone. METHODS A retrospective cohort study from January 2015 to December 2019 at Saint Joseph Mercy Ann Arbor. Patients were stratified into three groups based on anesthesia type: GETA, LRA, and dexmedetomidine (D) + LRA. Primary outcomes included stroke, myocardial infarction (MI), and death. Patient demographics were characterized and adjusted using propensity score weighting. RESULTS Three hundred seventy nine patients met inclusion criteria; 182 patients in the GETA group, 66 in the D + LRA, and 131 in LRA. There were no significant differences across anesthesia groups in primary outcomes of stroke, MI, and death during the admission. The GETA group had significantly longer length of stay (LOS) compared to the D + LRA group (LOS = 1.51 days versus 0.85 days; P = 0.011) and the LRA group (LOS = 1.08 days; P = 0.003). However, there was no significant difference in hospital LOS between the D + LRA group and LRA only groups (P = 0.952). There was no significant difference between stroke (LRA 0.87%, GETA 0.85%, and LRA + Dex 3.52%), MI (LRA 0%, GETA 0.49%, LRA + Dex 0%), or death (LRA 5.24%, GETA 1.16%, LRA + Dex 0%), within 30 days between all three of the anesthesia groups. There was no significant difference in postoperative pain scores when comparing the GETA group (mean 1.3, standard deviation [SD] 2.5) to LRA (mean 1.2, SD 2.1) and between LRA and D + LRA (mean 0.9, SD 2.1). Procedure time (time of skin incision to closure) and total room time were comparable among all three anesthesia groups (LRA 2.2 hr, SD 2.2; GETA 2.1 hr, SD 0.5; LRA + Dex 2.1 hr, SD 0.5). CONCLUSIONS The use of dexmedetomidine in addition to LRA is a safe and acceptable alternative to conventional GETA or LRA alone in CEA with shorter length of hospital stay when compared with GETA, improved patient tolerance based on physician observation, and similar rates of immediate and short-term complications and postoperative pain scores.
Collapse
Affiliation(s)
- Samik H Patel
- Department of Surgery, Section of Vascular and Endovascular Surgery, Trinity Health St. Joseph Mercy Ann Arbor, Ypsilanti, MI
| | - Vikram L Sundararaghavan
- Department of Surgery, Section of Vascular and Endovascular Surgery, Trinity Health St. Joseph Mercy Ann Arbor, Ypsilanti, MI
| | - Amber M Pawlikowski
- Department of Surgery, Section of Vascular and Endovascular Surgery, Trinity Health St. Joseph Mercy Ann Arbor, Ypsilanti, MI
| | - Jeremy Albright
- Department of Surgery, Section of Vascular and Endovascular Surgery, Trinity Health St. Joseph Mercy Ann Arbor, Ypsilanti, MI
| | - Jason M Adams
- Department of Surgery, Section of Vascular and Endovascular Surgery, Trinity Health St. Joseph Mercy Ann Arbor, Ypsilanti, MI
| | - Michael J Heidenreich
- Department of Surgery, Section of Vascular and Endovascular Surgery, Trinity Health St. Joseph Mercy Ann Arbor, Ypsilanti, MI
| | - Robert J Beaulieu
- Division of Vascular Diseases and Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Abdulhameed Aziz
- Department of Surgery, Section of Vascular and Endovascular Surgery, Trinity Health St. Joseph Mercy Ann Arbor, Ypsilanti, MI.
| |
Collapse
|
6
|
Boucher N, Dreksler H, Hooper J, Nagpal S, MirGhassemi A, Miller E. Anaesthesia for vascular emergencies - a state of the art review. Anaesthesia 2023; 78:236-246. [PMID: 36308289 DOI: 10.1111/anae.15899] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2022] [Indexed: 01/11/2023]
Abstract
In this state-of-the-art review, we discuss the presenting symptoms and management strategies for vascular emergencies. Although vascular emergencies are best treated at a vascular surgical centre, patients may present to any emergency department and may require both immediate management and safe transport to a vascular centre. We describe the surgical and anaesthetic considerations for management of aortic dissection, aortic rupture, carotid endarterectomy, acute limb ischaemia and mesenteric ischaemia. Important issues to consider in aortic dissection are extent of the dissection and surgical need for bypasses in addition to endovascular repair. From an anaesthetist's perspective, aortic dissection requires infrastructure for massive transfusion, smooth management should an endovascular procedure require conversion to an open procedure, haemodynamic manipulation during stent deployment and prevention of spinal cord ischaemia. Principles in management of aortic rupture, whether open or endovascular treatment is chosen, include immediate transfer to a vascular care centre; minimising haemodynamic changes to reduce aortic shear stress; permissive hypotension in the pre-operative period; and initiation of massive transfusion protocol. Carotid endarterectomy for carotid stenosis is managed with general or regional techniques, and anaesthetists must be prepared to manage haemodynamic, neurological and airway issues peri-operatively. Acute limb ischaemia is a result of embolism, thrombosis, dissection or trauma, and may be treated with open repair or embolectomy, under either general or local anaesthesia. Due to hypercoagulability, there may be higher numbers of acutely ischaemic limbs among patients with COVID-19, which is important to consider in the current pandemic. Mesenteric ischaemia is a rare vascular emergency, but it is challenging to diagnose and associated with high morbidity and mortality. Several peri-operative issues are common to all vascular emergencies: acute renal injury; management of transfusion; need for heparinisation and reversal; and challenging postoperative care. Finally, the important development of endovascular techniques for repair in many vascular emergencies has improved care, and the availability of transoesophageal echocardiography has improved monitoring as well as aids in surgical placement of endovascular grafts and for post-procedural evaluation.
Collapse
Affiliation(s)
- N Boucher
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada
| | - H Dreksler
- Division of Vascular Surgery, Department of Surgery, University of Ottawa, ON, Canada
| | - J Hooper
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada.,Department of Critical Care, The Ottawa Hospital, University of Ottawa, ON, Canada
| | - S Nagpal
- Division of Vascular Surgery, Department of Surgery, University of Ottawa, ON, Canada
| | - A MirGhassemi
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada
| | - E Miller
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada
| |
Collapse
|
7
|
Paramasivan NK, Sylaja PN, Pitchai S, Madathipat U, Sreedharan SE, Sukumaran S, Vinoda Thulaseedharan J. Carotid Endarterectomy for Symptomatic Carotid Stenosis: Differences in Patient Profile in a Low-Middle-Income Country. Cerebrovasc Dis Extra 2022; 13:56-62. [PMID: 36481594 PMCID: PMC10080201 DOI: 10.1159/000528515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/20/2022] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Carotid endarterectomy (CEA) is the standard treatment for patients with symptomatic carotid stenosis. Data from low- and middle-income countries are sparse on CEA and its outcomes. We aimed to describe the profile of our patients and factors associated with periprocedural cerebral ischemic events in patients with symptomatic carotid stenosis who underwent CEA in our institute. METHODS Retrospective review of patients with symptomatic carotid stenosis (50-99%) who underwent CEA between January 2011 and December 2021 was done. Clinical and imaging parameters and their influence on periprocedural cerebral ischemic events were analyzed. RESULTS Of the 319 patients (77% males) with a mean age of 64 years (SD±8.6), 207 (65%) presented only after a stroke. Majority (85%) had high-grade stenosis (≥70%) of the symptomatic carotid. The mean time to CEA was 50 days (SD±36); however, only 26 patients (8.2%) underwent surgery within 2 weeks. Minor strokes and TIA occurred in 2.2%, while major strokes and death occurred in 4.1% patients. None of the clinical or imaging parameters predicted the periprocedural cerebral ischemic events. The presence of co-existing significant (≥50%) tandem intracranial atherosclerosis (n = 77, 24%) or contralateral occlusion (n = 24, 7.5%) did not influence the periprocedural stroke risk. CONCLUSION There is a delay in patients undergoing CEA for symptomatic carotid stenosis. Majority have high-grade stenosis and present late only after a stroke reflecting a lack of awareness. CEA can be performed safely even in patients with significant intracranial tandem stenosis and contralateral carotid occlusion.
Collapse
Affiliation(s)
- Naveen Kumar Paramasivan
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Padmavathy N Sylaja
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Shivanesan Pitchai
- Department of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Unnikrishnan Madathipat
- Department of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Sapna Erat Sreedharan
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Sajith Sukumaran
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Jissa Vinoda Thulaseedharan
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| |
Collapse
|
8
|
Tomas VG, Hollis N, Ouanes JPP. Regional Anesthesia for Vascular Surgery and Pain Management. Anesthesiol Clin 2022; 40:751-773. [PMID: 36328627 DOI: 10.1016/j.anclin.2022.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Patients undergoing vascular surgery tend to have significant systemic comorbidities. Vascular surgery itself is also associated with greater cardiac morbidity and overall mortality than other types of noncardiac surgery. Regional anesthesia is amenable as the primary anesthetic technique for vascular surgery or as an adjunct to general anesthesia. When used as the primary anesthetic, regional anesthesia techniques avoid complications associated with general anesthesia in this challenging patient population. In this article, the authors describe regional anesthetic techniques for carotid endarterectomy, arteriovenous fistula creation, lower extremity bypass surgery, and amputation.
Collapse
Affiliation(s)
- Vicente Garcia Tomas
- Department of Anesthesiology, Regional Anesthesia and Acute Pain Medicine, Northwestern University Feinberg School of Medicine Chicago, 251 E. Huron St F5-704, Chicago, IL 60611, USA.
| | - Nicole Hollis
- Department of Anesthesiology, West Virginia University, 1 Medical Center Drive PO Box 8255, Morgantown, WV 26508, USA
| | - Jean-Pierre P Ouanes
- Cornell Medicine, Hospital for Special Surgery, Florida, 300 Palm Beach Lakes Boulevard, West Palm Beach, FL 33401, USA
| |
Collapse
|
9
|
Doherty Z, Savage N, Milne C, Pilcher D. Vascular surgery patients in intensive care: a bi-national cohort study over 15 years. ANZ J Surg 2022. [PMID: 36189984 DOI: 10.1111/ans.18080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 09/13/2022] [Accepted: 09/18/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND To describe the characteristics and outcomes of patients admitted to Intensive Care following vascular surgery, and their subsequent usage of Intensive Care resources, over a 15-year period in Australia and New Zealand. METHODS This was a retrospective, bi-national study of 69 676 adult patients admitted to 179 Intensive Care Unit (ICUs) following vascular surgery between January 2005 and December 2019, using the Australian and New Zealand Intensive Care Society Adult Patient Database. RESULTS The proportion of ICU bed days used by vascular surgery patients decreased during the study period from 3.6% in 2005 to 2.9% in 2019 (P < 0.001). The cohort had a median age of 73 years, and were most frequently admitted after a carotid endarterectomy (22%) or elective open aneurysm repair (20%). A total of 5.2% of patients did not survive to discharge. Mean annual adjusted mortality decreased during the study period from 6.1% in 2005 to 3.7% in 2019 (P < 0.001). Multiple factors were associated with higher mortality, including gender, hospital case volume and hospital type. CONCLUSIONS Between 2005 and 2019 survival for vascular surgery patients requiring ICU admission in Australia and New Zealand improved. During the same time the proportion of ICU bed days used by these patients decreased.
Collapse
Affiliation(s)
- Zakary Doherty
- School of Rural Health, Monash University, Bendigo, Victoria, Australia.,Department of Surgery, Alfred Health, Melbourne, Victoria, Australia.,Department of Medicine, Alfred Health, Melbourne, Victoria, Australia
| | - Nicholas Savage
- Department of Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Charles Milne
- Department of Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - David Pilcher
- Department of Surgery, Alfred Health, Melbourne, Victoria, Australia.,The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation, Melbourne, Victoria, Australia.,The Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
10
|
Vuurberg NE, Post ICJH, Keller BPJA, Schaafsma A, Vos CG. A systematic review & meta-analysis on perioperative cerebral and hemodynamic monitoring methods during carotid endarterectomy. Ann Vasc Surg 2022; 88:385-409. [PMID: 36100123 DOI: 10.1016/j.avsg.2022.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 08/23/2022] [Accepted: 08/31/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To compare outcomes between different strategies of perioperative cerebral and hemodynamic monitoring during carotid endarterectomy. DATA SOURCES MEDLINE, EMBASE, CINAHL, and Cochrane CENTRAL databases were searched. METHODS This review was performed according to the PRISMA guidelines and prospectively registered in the international prospective register of systematic reviews (CRD42021241891). The GRADE approach was used to describe the methodological quality of the studies and certainty of the evidence. The primary outcome was 30-day stroke rate. Secondary outcomes measures are 30-day ipsilateral stroke, 30-day mortality, shunt rate and complication rates. RESULTS The search identified 3 460 articles. Seventeen RCTs, three prospective observational studies and seven registries were included, reporting on 236 983 patients. The overall pooled 30-day stroke rate is 1.8% (95% CI 1.4 - 2.2%), ranging from 0 - 12.6%. In RCT's the pooled 30-day stroke rate is 2.7% (95% CI 1.6 - 3.7%) compared to 1.3% (95%CI 0.8 - 1.8%) in the registries. The overall stroke risk decreased from 3.7% before the year 2000 to 1.6% after 2000. No significant differences could be identified between different monitoring and shunting strategies, although a trend to higher stroke rates in routine no shunting arms of RCTs was observed. Overall 30-day mortality, myocardial infarction and nerve injury rates are 0.6% (95%CI 0.4 - 0.8), 0.8% (95%CI 0.6-1.0) and 1.3% (95%CI 0.4-2.2), respectively. CONCLUSIONS No significant differences between the compared shunting and monitoring strategies are found. However, routine no shunting is not recommended. The available data is too limited to prefer one method of neuromonitoring over another method when selective shunting is applied.
Collapse
Affiliation(s)
| | - Ivo C J H Post
- Department of Surgery, Martini Hospital, Groningen, The Netherlands
| | | | - Arjen Schaafsma
- Department of Clinical Neurophysiology & Neurology, Martini Hospital, Groningen, The Netherlands
| | - Cornelis G Vos
- Department of Surgery, Martini Hospital, Groningen, The Netherlands.
| |
Collapse
|
11
|
BEYAZ MO, URFALI S, KAYA S, ORUÇ D, ÇÖMEZ M, HAKİMOĞLU S, KOYUNCU O, MELEK I, FANSA İ. Servikal blok altında karotis endarterektomi operasyonu sonuçlarımız: Anadolu’da bir merkezde ilk uygulama. MUSTAFA KEMAL ÜNIVERSITESI TIP DERGISI 2022. [DOI: 10.17944/mkutfd.1061031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
|
12
|
van Gaal S, Alimohammadi A, Yu AYX, Karim ME, Zhang W, Sutherland JM. Accurate classification of carotid endarterectomy indication using physician claims and hospital discharge data. BMC Health Serv Res 2022; 22:379. [PMID: 35317793 PMCID: PMC8941812 DOI: 10.1186/s12913-022-07614-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 02/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AND PURPOSE Studies of carotid endarterectomy (CEA) require stratification by symptomatic vs asymptomatic status because of marked differences in benefits and harms. In administrative datasets, this classification has been done using hospital discharge diagnosis codes of uncertain accuracy. This study aims to develop and evaluate algorithms for classifying symptomatic status using hospital discharge and physician claims data. METHODS A single center's administrative database was used to assemble a retrospective cohort of participants with CEA. Symptomatic status was ascertained by chart review prior to linkage with physician claims and hospital discharge data. Accuracy of rule-based classification by discharge diagnosis codes was measured by sensitivity and specificity. Elastic net logistic regression and random forest models combining physician claims and discharge data were generated from the training set and assessed in a test set of final year participants. Models were compared to rule-based classification using sensitivity at fixed specificity. RESULTS We identified 971 participants undergoing CEA at the Vancouver General Hospital (Vancouver, Canada) between January 1, 2008 and December 31, 2016. Of these, 729 met inclusion/exclusion criteria (n = 615 training, n = 114 test). Classification of symptomatic status using hospital discharge diagnosis codes was 32.8% (95% CI 29-37%) sensitive and 98.6% specific (96-100%). At matched 98.6% specificity, models that incorporated physician claims data were significantly more sensitive: elastic net 69.4% (59-82%) and random forest 78.8% (69-88%). CONCLUSION Discharge diagnoses were specific but insensitive for the classification of CEA symptomatic status. Elastic net and random forest machine learning algorithms that included physician claims data were sensitive and specific, and are likely an improvement over current state of classification by discharge diagnosis alone.
Collapse
Affiliation(s)
- Stephen van Gaal
- Faculty of Medicine, University of British Columbia, 8161-2775 Laurel Street, Vancouver, BC, V5Z1M9, Canada.
| | - Arshia Alimohammadi
- Faculty of Medicine, University of British Columbia, 8161-2775 Laurel Street, Vancouver, BC, V5Z1M9, Canada
| | - Amy Y X Yu
- Department of Medicine (Neurology), University of Toronto, Toronto, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Mohammad Ehsanul Karim
- School of Population and Public Health, University of British Columbia, Centre for Health Evaluation and Outcome Sciences, Vancouver, Canada
| | - Wei Zhang
- School of Population and Public Health, University of British Columbia, Centre for Health Evaluation and Outcome Sciences, Vancouver, Canada
| | - Jason M Sutherland
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, Canada
| |
Collapse
|
13
|
Moacdieh MP, Khan MA, Layman P, Elsayed N, Malas MB. Innovation in the open and endovascular treatment of carotid artery stenosis. Semin Vasc Surg 2021; 34:163-171. [PMID: 34911622 DOI: 10.1053/j.semvascsurg.2021.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Munir P Moacdieh
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093
| | - Maryam A Khan
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093
| | - Peter Layman
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093
| | - Nadin Elsayed
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093.
| |
Collapse
|
14
|
Elsayed N, Ramakrishnan G, Naazie I, Sheth S, Malas MB. Outcomes of Carotid Revascularization in the Treatment of Restenosis After Prior Carotid Endarterectomy. Stroke 2021; 52:3199-3208. [PMID: 34281373 DOI: 10.1161/strokeaha.120.033667] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE Restenosis after carotid endarterectomy (CEA) is associated with an increased risk of ipsilateral stroke. The optimal procedural modality for this indication has yet to be determined. Here, we evaluate the in-hospital outcomes of transcarotid artery revascularization (TCAR), redo-CEA, and transfemoral carotid artery stenting (TFCAS) in a large contemporary cohort of patients who underwent treatment for restenosis after CEA. METHODS We performed a retrospective analysis of all patients in the vascular quality initiative database who underwent TCAR, redo-CEA, or TFCAS after ipsilateral CEA between September 2016 and April 2020. Patients with prior ipsilateral CAS were excluded from this analysis. In-hospital outcomes following TCAR versus CEA and TCAR versus TFCAS were evaluated using multivariate logistic regression analysis. RESULTS A total of 4425 patients were available for this analysis. There were 963 (21.8%) redo-CEA, 1786 (40.4%) TFCAS, and 1676 (37.9%) TCAR. TCAR was associated with lower odds of in-hospital stroke/death (odds ratio [OR], 0.41 [95% CI, 0.24-0.70], P=0.021), stroke (OR, 0.46 [95% CI, 0.23-0.93], P=0.03), myocardial infarction (MI; OR, 0.32 [95% CI, 0.14-0.73], P=0.007), stroke/transient ischemic attack (OR, 0.42 [95% CI, 0.24-0.74], P=0.002), and stroke/death/MI (OR, 0.41 [95% CI, 0.24-0.70], P=0.001) when compared with redo-CEA. There was no significant difference in the odds of death between the 2 groups (OR, 0.99 [95% CI, 0.28-3.5], P=0.995). TCAR was also associated with lower odds of stroke/transient ischemic attack (OR, 0.37 [95% CI, 0.18-0.74], P=0.005) when compared with TFCAS. There was no significant difference in the odds of stroke, death, MI, stroke/death, or stroke/death/MI between TCAR and TFCAS. CONCLUSIONS TCAR was associated with significantly lower odds of in-hospital stroke, MI, stroke/transient ischemic attack, stroke/death, and stroke/death/MI when compared with redo-CEA and lower odds of in-hospital stroke/transient ischemic attack when compared with TFCAS. Additional long-term studies are warranted to establish the role of TCAR for the treatment of restenosis after CEA.
Collapse
Affiliation(s)
- Nadin Elsayed
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla (N.E., I.N., M.B.M.)
| | | | - Isaac Naazie
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla (N.E., I.N., M.B.M.)
| | - Sharvil Sheth
- Division of Vascular and Endovascular Surgery, St Luke's University Health Network, Bethlehem, PA (S.S.)
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla (N.E., I.N., M.B.M.)
| |
Collapse
|
15
|
AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
| |
Collapse
|
16
|
Tauber H, Streif W, Gebetsberger J, Gasteiger L, Pierer E, Knoflach M, Fraedrich G, Gummerer M, Fritz J, Velik-Salchner C. Cardiac output and cerebral blood flow during carotid surgery in regional versus general anesthesia: A prospective randomized controlled study. J Vasc Surg 2021; 74:930-937.e2. [PMID: 33887429 DOI: 10.1016/j.jvs.2021.03.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 03/19/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) is a preventive procedure aimed at decreasing the subsequent risk of fatal or disabling stroke in patients with significant carotid stenosis. It is well-known that carotid surgery under ultrasound-guided regional anesthesia (US-RA) causes a significant increase in blood pressure, heart rate and stress hormone levels owing to increased sympathetic activity. However, little is known about the effects on cardiac output (CO), cardiac index (CI), and cerebral blood flow (CBF) under US-RA as compared with general anesthesia (GA). METHODS Patients scheduled for CEA were randomized prospectively to receive US-RA (n = 37) or GA (n = 41). The primary end point was the change in CI after induction of anesthesia and the change from baseline over time at four different times during the entire procedure in the respective randomized US-RA and GA groups. In addition to systolic blood pressure and heart rate, we also recorded peak systolic velocity, end-diastolic velocity, and minimum diastolic velocity as seen from transcranial Doppler ultrasound examination, as well as regional cerebral oxygenation (rSO2) as seen from near-infrared refracted spectroscopy to evaluate cerebral blood flow. RESULTS In the US-RA group, the CI increased after induction of anesthesia (3.7 ± 0.8 L/min/m2) and remained constant until the end of the procedure. In the GA group CI was significantly lower (2.4 ± 0.6 L/min/m2; P < .001). After induction of anesthesia, the rSO2 remained constant in the GA group on both the ipsilateral (63 ± 9 rSO2) and the contralateral (65 ± 7 rSO2) sides; in contrast, it significantly increased in the US-RA group (ipsilateral 72 ± 8 rSO2; P < .001; contralateral 72 ± 6 rSO2; P < .001). The transcranial Doppler ultrasound parameters (peak systolic velocity, end-diastolic velocity, and minimum diastolic velocity) did not differ between the US-RA and the GA group. The clinical outcome was similarly favorable for both groups. CONCLUSIONS CI was maintained near baseline values throughout the procedure during US-RA, whereas a significant decrease in CI values was observed during CEA under GA. Near-infrared refracted spectroscopy values, reflecting blood flow in small vessels, were higher in US-RA patients than in those with GA. These differences did not influence clinical outcome.
Collapse
Affiliation(s)
- Helmuth Tauber
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Werner Streif
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Lukas Gasteiger
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Eve Pierer
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Maria Gummerer
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Josef Fritz
- Department of Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Innsbruck, Austria
| | - Corinna Velik-Salchner
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria.
| |
Collapse
|
17
|
Marmor RA, Dakour-Aridi H, Chen ZG, Naazie I, Malas MB. Anesthetic choice during transcarotid artery revascularization and carotid endarterectomy affects the risk of myocardial infarction. J Vasc Surg 2021; 74:1281-1289. [PMID: 33887427 DOI: 10.1016/j.jvs.2021.03.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 03/15/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Previous studies have shown no differences in the outcomes of transcarotid artery revascularization (TCAR) performed with general anesthesia (GA) vs local or regional anesthesia (LRA). To date, no study has specifically compared the outcomes of TCAR to those of carotid endarterectomy (CEA) stratified by anesthetic type. The aim of the present study was to identify the effect of the anesthetic type on the outcomes of TCAR vs CEA. METHODS Patients undergoing CEA and TCAR for carotid artery stenosis from 2016 to 2019 in the Vascular Quality Initiative were included. We excluded patients who had undergone concomitant procedures, patients with more than two stented lesions, and patients who had undergone the procedure for a nonatherosclerotic indication. Propensity score matching was performed between the two procedures stratified by the anesthetic type for age, sex, race, presenting symptoms, major comorbidities (ie, hypertension, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease), previous coronary artery bypass grafting or percutaneous transluminal coronary intervention, previous CEA or carotid artery stenting, degree of ipsilateral stenosis, the presence of contralateral occlusion, and preoperative medications. Intergroup differences between the treatment groups and differences in the perioperative outcomes were tested using the McNemar test for categorical variables and the paired t test or Wilcoxon matched pairs signed rank test for continuous variables, as appropriate. The relative risk (RR) and 95% confidence intervals (CIs) were estimated as the ratio of the probability of the outcome event for the patients treated within each treatment group. RESULTS A total of 65,337 patients were included. Of the 65,337 patients, 59,664 had undergone carotid revascularization under GA (91%). When performed with LRA, TCAR and CEA had similar rates of stroke, death, and MI. However, when performed with GA, patients undergoing TCAR had a 50% decreased risk of MI compared with those undergoing CEA under GA (0.5% vs 1.0%; RR, 0.50; 95% CI, 0.32-0.80; P < .01). When stratified by symptomatic status, patients undergoing TCAR with GA for symptomatic carotid disease had a 67% decreased risk of MI compared with those undergoing CEA with GA for symptomatic disease (0.4% vs 1.2%; RR, 0.33; 95% CI, 0.15-0.75; P < .01). In contrast, no difference was found in the risk of MI between patients undergoing CEA vs TCAR for asymptomatic carotid disease (0.6% vs 0.9%; RR, 0.64; 95% CI, 0.37-1.14; P = .13). CONCLUSIONS The results from the present study have confirmed previous studies suggesting that TCAR confers a lower risk of MI compared with CEA. However, our findings demonstrated no differences in the MI rates between TCAR and CEA when performed with LRA. Patients undergoing TCAR under GA had lower rates of MI compared with patients undergoing CEA under GA. When stratified by symptomatic status, the benefit of TCAR persisted only for the symptomatic patients.
Collapse
Affiliation(s)
- Rebecca A Marmor
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, Calif
| | - Hanaa Dakour-Aridi
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Zuo-Guan Chen
- Department of Vascular Surgery, Beijing Hospital, Chinese Medical Academy of Sciences, Peking Union Medical College, and Tsinghua University, Beijing, People's Republic of China
| | - Isaac Naazie
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, Calif
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, Calif.
| |
Collapse
|
18
|
Pereira-Neves A, Rocha-Neves J, Fragão-Marques M, Duarte-Gamas L, Jácome F, Coelho A, Cerqueira A, Andrade JP, Mansilha A. Red blood cell distribution width is associated with hypoperfusion in carotid endarterectomy under regional anesthesia. Surgery 2021; 169:1536-1543. [PMID: 33610341 DOI: 10.1016/j.surg.2021.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/22/2020] [Accepted: 01/06/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND A subset of patients submitted to carotid endarterectomy under regional anesthesia develop intraoperative neurologic deficit during carotid artery crossclamping related to critical cerebral perfusion, which may be owing to low flow or embolic phenomena. This subgroup is deemed prone to worse outcomes, which highlights its clinical relevance. The main aim of this study was to identify clinical and hematological predictors for intraoperative neurologic deficit. The secondary aim was to evaluate the perioperative prognostic value of postcarotid artery crossclamping manifestations of cerebral ischemia. METHODS Between January 2012 to January 2020, patients submitted to carotid endarterectomy under regional anesthesia in a tertiary referral center who presented intraoperative neurologic deficit were prospectively and consecutively included. This group constituted 8% of the total carotid endarterectomy performed in the center during this timeframe. The control group of patients was the subsequent patient submitted to carotid endarterectomy without intraoperative neurologic deficit in a 1:1 ratio. Blood samples were collected before surgery (<2 weeks). Propensity score matching was used to identify well-matched pairs of patients. RESULTS A total of 180 patients were included, with 90 (50% of the cohort and 8% of total carotid endarterectomies) presenting intraoperative neurologic deficit associated to clamping. Mean age was 71.4 ± 9.27 years in the study group and 68.8 ± 8.36 years in the control group. The clinical variables presenting significance after multivariate analysis include: age (adjusted odds ratio: 1.04, 5-95% confidence interval, [1.003-1.078]; P = .034), obesity (adjusted odds ratio: 3.537 [1.445-8.658]; P = .006), lower ipsilateral carotid stenosis grade (adjusted odds ratio: 0.725 [0.525-0.997]; P = .049), and higher contralateral carotid stenosis grade (adjusted odds ratio: 1.266 [1.057-1.516]; P = .010). Red cell distribution width coefficient of variation demonstrated statistical significance in predicting intraoperative neurologic deficit with an adjusted odds ratio of 1.394 (1.076-1.805); P = .012. The 30-day stroke rate was significantly higher in the intraoperative neurologic deficit group, with an adjusted odds ratio of 5.13 (5-95% confidence interval [1.058-24.87]; P = .042) after propensity score matching. Postoperative complications (Clavien-Dindo ≥2) were also associated with intraoperative neurologic deficit (after propensity score matching adjusted odds ratio of 2.748 [5-95% confidence interval, 0.976-7.741]; P = .051). CONCLUSION In this study, increased red cell distribution width coefficient of variation demonstrated value to predict intraoperative neurologic deficit. Additionally, age, obesity, a lower degree of ipsilateral carotid stenosis, and a higher degree of contralateral carotid stenosis also demonstrated ability to predict intraoperative neurologic deficit. Moreover, intraoperative neurologic deficit was an independent risk factor for 30-day stroke and postoperative complications Clavien-Dindo ≥2.
Collapse
Affiliation(s)
- António Pereira-Neves
- Department of Biomedicine-Unit of Anatomy, Faculdade de Medicina da Universidade do Porto, Portugal; Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal.
| | - João Rocha-Neves
- Department of Biomedicine-Unit of Anatomy, Faculdade de Medicina da Universidade do Porto, Portugal; Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal
| | - Mariana Fragão-Marques
- Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal; Department of Clinical Pathology, Centro Hospitalar Universitário de São João, Porto, Portugal; Cardiovascular R & D Unit, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Luís Duarte-Gamas
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal
| | - Filipa Jácome
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal
| | - Andreia Coelho
- Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal; Department of Angiology and Vascular Surgery, Centro Hospitalar Vila Nova de Gaia e Espinho, Portugal
| | - Alfredo Cerqueira
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - José P Andrade
- Department of Biomedicine-Unit of Anatomy, Faculdade de Medicina da Universidade do Porto, Portugal; Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
| | - Armando Mansilha
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal
| |
Collapse
|
19
|
Colegrave N, Mascitti P, Zannis K, Miceli P, Veugeois A, Caussin C, Philip I. Ultrasound-Guided Intermediate Cervical Plexus Block for Transcarotid Transcatheter Aortic Valve Replacement. J Cardiothorac Vasc Anesth 2020; 35:1747-1750. [PMID: 32948407 DOI: 10.1053/j.jvca.2020.08.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/20/2020] [Accepted: 08/21/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To report the authors' initial experience of transcarotid transcatheter aortic valve replacement (TAVR) managed with ultrasound-guided intermediate cervical plexus block. DESIGN A single-center prospective study. SETTING A teaching hospital in Paris, France. PARTICIPANTS All consecutive patients undergoing a transcarotid TAVR were included. INTERVENTIONS The ultrasound-guided intermediate cervical plexus block was performed in 28 of 31 patients. In 3 patients, the procedure was scheduled under general anesthesia: 2 because of failure of previous transfemoral procedures under local anesthesia, and 1 for an emergency procedure in a pulmonary edema context. MEASUREMENTS AND MAIN RESULTS Anesthesia and all perioperative parameters were recorded, as well as any complications after the procedure. Twenty-eight patients were managed with intermediate cervical plexus block and light sedation without any anesthesia-related complication. No conversion to general anesthesia was required. The use of vasopressor was only required in 11% of the patients. In 2 patients, a loss of consciousness after the common carotid artery cross-clamping test occurred, leading to the use of a temporary femoral-carotid shunt; no other change in consciousness was recorded during the procedure. CONCLUSIONS Ultrasound-guided intermediate cervical plexus block appeared to be an alternative anesthetic technique for carotid TAVR, providing adequate surgical conditions, continuous neurologic monitoring, and arterial pressure stability.
Collapse
Affiliation(s)
- Nora Colegrave
- Department of Anesthesiology, Institut Mutualiste Montsouris, Paris, France
| | - Paola Mascitti
- Department of Anesthesiology, Institut Mutualiste Montsouris, Paris, France
| | - Konstandinos Zannis
- Department of Cardiology and Cardiac Surgery, Institut Mutualiste Montsouris, Paris, France
| | - PierLuigi Miceli
- Department of Anesthesiology, Institut Mutualiste Montsouris, Paris, France
| | - Aurélie Veugeois
- Department of Cardiology and Cardiac Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Christophe Caussin
- Department of Cardiology and Cardiac Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Ivan Philip
- Department of Anesthesiology, Institut Mutualiste Montsouris, Paris, France.
| |
Collapse
|
20
|
Dakour-Aridi H, Gaber MG, Khalid M, Patterson R, Malas MB. Examination of the interaction between method of anesthesia and shunting with carotid endarterectomy. J Vasc Surg 2020; 71:1964-1971. [DOI: 10.1016/j.jvs.2019.08.248] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 08/06/2019] [Indexed: 10/25/2022]
|
21
|
Mukherjee D, Collins DT, Liu C, Ha N, Jim J. The study of transcarotid artery revascularization under local versus general anesthesia with results from the Society for Vascular Surgery Vascular Quality Initiative. Vascular 2020; 28:784-793. [DOI: 10.1177/1708538120924158] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective The primary purpose of this study was to examine any potential difference in clinical outcomes between transcarotid artery revascularization performed under local anesthesia compared with general anesthesia by utilizing a large national database. Methods The primary outcome of the study was a composite endpoint of postoperative in-hospital stroke, myocardial infarction and mortality following transcarotid artery revascularization for the index procedure. Secondary outcomes included a composite outcome of postoperative in-hospital stroke, transient ischemic attack, myocardial infarction and mortality along with several subsets of its components and each individual component, flow reversal time (min), radiation dose (GY/cm2), contrast volume utilized (mL), total procedure time (min), extended total length of stay (>1 day) and extended postoperative length of stay (>1 day). Statistical analyses employed both descriptive measures to characterize the study population and analytic measures such as multivariable mixed-effect linear and logistic regressions using both unmatched and propensity-score matched cohorts. Results A total of 2609 patients undergoing transcarotid artery revascularization between the years 2016 and 2018 in the US were identified, with 82.3% performed under general anesthesia and 17.7% under local anesthesia. The primary composite outcome was observed in 2.3% of general anesthesia patients versus 2.6% of local anesthesia patients ( p = 0.808). The rate of postoperative transient ischemic attack and/or myocardial infarction was 1.6% with general anesthesia versus 1.1% with local anesthesia ( p = 0.511). For adjusted regression analysis, general anesthesia and local anesthesia were comparable in terms of primary outcome (OR: 0.72; 95% CI: 0.27–1.93, p = 0.515). As for the secondary outcomes, no significant differences were found except for contrast, where the results demonstrated significantly less need for contrast with procedures performed under general anesthesia (coefficient: 4.94; 95% CI: 1.34–8.54, p = 0.007). A trend towards significance was observed for lower rate of postoperative transient ischemic attack and/or myocardial infarction (OR: 0.33; 95% CI: 0.09–1.18, p = 0.088) and lower flow reversal time under local anesthesia (coefficient: –0.94: 95% CI: –2.1–0.22, p = 0.111). Conclusions Excellent outcomes from transcarotid artery revascularization for carotid stenosis were observed in the VQI database between the years 2016 and 2018, under both local anesthesia and general anesthesia. The data demonstrate the choice of anesthesia for transcarotid artery revascularization does not appear to have any effect on clinical outcomes. Surgical teams should perform transcarotid artery revascularization under the anesthesia type they are most comfortable with.
Collapse
Affiliation(s)
| | - Devon T Collins
- Department of Community and Global Health, Inova Heart and Vascular Institute, Inova Fairfax Hospital, College of Health and Human Services, George Mason University, Fairfax, VA, USA
| | - Chang Liu
- Department of Surgery, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Neul Ha
- Department of Surgery, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Jeffrey Jim
- Section of Vascular Surgery, School of Medicine, Washington University, St. Louis, MO, USA
| |
Collapse
|
22
|
Regional anesthesia for vascular surgery: does the anesthetic choice influence outcome? Curr Opin Anaesthesiol 2020; 32:690-696. [PMID: 31415047 DOI: 10.1097/aco.0000000000000781] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Outcomes following surgery are of major importance to clinicians, institutions and most importantly patients. This review examines whether regional anesthesia and analgesia influence outcome after vascular surgery. RECENT FINDINGS Large database analyses of contemporary practice suggest that utilizing regional anesthesia for both open and endovascular aortic aneurysm repair, lower limb revascularization and carotid endarterectomy reduces morbidity, length of stay and possibly even mortality. Results from such analyses are limited by an inherent risk of bias but are nevertheless important given the number of patients required in randomized trials to detect differences in rare outcomes. There is minimal evidence that regional anesthesia influences longer term outcomes except for arteriovenous fistula surgery where brachial plexus blocks appear to improve 3-month fistula patency. SUMMARY Patients undergoing vascular surgery often have multiple comorbidities and it is important to be able to outline both benefits and risks of regional anesthesia techniques. Regional anesthesia in vascular surgery allows avoidance of general anesthesia and does provide short-term benefits beyond superior analgesia. Evidence of long-term benefits is lacking in most procedures. Further work is required on newer patient centered outcomes.
Collapse
|
23
|
Fereydooni A, O'Meara T, Popescu WM, Dardik A, Ochoa Chaar CI. Utilization and Outcomes of Local Anesthesia and Peripheral Nerve Block for Hybrid Lower Extremity Revascularization. J Endovasc Ther 2019; 27:94-101. [PMID: 31746264 DOI: 10.1177/1526602819887382] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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.
Collapse
Affiliation(s)
| | | | - Wanda M Popescu
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT, USA
| | - Alan Dardik
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
24
|
Knappich C, Kuehnl A, Haller B, Salvermoser M, Algra A, Becquemin JP, Bonati LH, Bulbulia R, Calvet D, Fraedrich G, Gregson J, Halliday A, Hendrikse J, Howard G, Jansen O, Malas MB, Ringleb PA, Brown MM, Mas JL, Brott TG, Morris DR, Lewis SC, Eckstein HH. Associations of Perioperative Variables With the 30-Day Risk of Stroke or Death in Carotid Endarterectomy for Symptomatic Carotid Stenosis. Stroke 2019; 50:3439-3448. [PMID: 31735137 DOI: 10.1161/strokeaha.119.026320] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background and Purpose- This analysis was performed to assess the association between perioperative and clinical variables and the 30-day risk of stroke or death after carotid endarterectomy for symptomatic carotid stenosis. Methods- Individual patient-level data from the 5 largest randomized controlled carotid trials were pooled in the Carotid Stenosis Trialists' Collaboration database. A total of 4181 patients who received carotid endarterectomy for symptomatic stenosis per protocol were included. Determinants of outcome included carotid endarterectomy technique, type of anesthesia, intraoperative neurophysiological monitoring, shunting, antiplatelet medication, and clinical variables. Stroke or death within 30 days after carotid endarterectomy was the primary outcome. Adjusted risk ratios (aRRs) were estimated in multilevel multivariable analyses using a Poisson regression model. Results- Mean age was 69.5±9.2 years (70.7% men). The 30-day stroke or death rate was 4.3%. In the multivariable regression analysis, local anesthesia was associated with a lower primary outcome rate (versus general anesthesia; aRR, 0.70 [95% CI, 0.50-0.99]). Shunting (aRR, 1.43 [95% CI, 1.05-1.95]), a contralateral high-grade carotid stenosis or occlusion (aRR, 1.58 [95% CI, 1.02-2.47]), and a more severe neurological deficit (mRS, 3-5 versus 0-2: aRR, 2.51 [95% CI, 1.30-4.83]) were associated with higher primary outcome rates. None of the other characteristics were significantly associated with the perioperative stroke or death risk. Conclusions- The current results indicate lower perioperative stroke or death rates in patients operated upon under local anesthesia, whereas a more severe neurological deficit and a contralateral high-grade carotid stenosis or occlusion were identified as potential risk factors. Despite a possible selection bias and patients not having been randomized, these findings might be useful to guide surgeons and anesthetists when treating patients with symptomatic carotid disease.
Collapse
Affiliation(s)
- Christoph Knappich
- From the Department for Vascular and Endovascular Surgery (C.K., A.K., M.S., H.-H.E.), Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Andreas Kuehnl
- From the Department for Vascular and Endovascular Surgery (C.K., A.K., M.S., H.-H.E.), Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Bernhard Haller
- Institute of Medical Informatics, Statistics and Epidemiology (B.H.), Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Michael Salvermoser
- From the Department for Vascular and Endovascular Surgery (C.K., A.K., M.S., H.-H.E.), Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus and Julius Centre for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, the Netherlands
| | - Jean-Pierre Becquemin
- Vascular Institute Paris East, Private Hospital Paul D'Egine, Ramsay Group, Champigny sur Marne, France (J.-P.B.)
| | - Leo H Bonati
- Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland
- Department of Clinical Research (L.H.B.), University Hospital Basel, Switzerland
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London, United Kingdom (L.H.B., M.M.B.)
| | - Richard Bulbulia
- Clinical Trial Service Unit and Epidemiological Studies Unit (R.B., D.R.M.), Nuffield Department of Population Health, University of Oxford, United Kingdom
- Medical Research Council Population Health Research Unit (R.B.), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | | | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Austria (G.F.)
| | - John Gregson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, United Kingdom (J.G.)
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, United Kingdom (A.H.)
| | - Jeroen Hendrikse
- Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands
| | - George Howard
- Department of Biostatistics, UAB School of Public Health, Birmingham, AL (G.H.)
| | - Olav Jansen
- Department of Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.)
| | - Mahmoud B Malas
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California San Diego, Health System (M.B.M.)
| | - Peter A Ringleb
- Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.)
| | - Martin M Brown
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London, United Kingdom (L.H.B., M.M.B.)
| | | | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.)
| | - Dylan R Morris
- Clinical Trial Service Unit and Epidemiological Studies Unit (R.B., D.R.M.), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Steff C Lewis
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, United Kingdom (S.C.L.)
| | - Hans-Henning Eckstein
- From the Department for Vascular and Endovascular Surgery (C.K., A.K., M.S., H.-H.E.), Klinikum rechts der Isar, Technical University of Munich, Germany
| |
Collapse
|
25
|
Utilization of regional versus general anesthesia and its impact on lower extremity bypass outcomes. J Vasc Surg 2019; 69:1874-1879. [PMID: 30792062 DOI: 10.1016/j.jvs.2018.08.190] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 08/31/2018] [Indexed: 11/23/2022]
|
26
|
Noninvasive continuous arterial pressure monitoring with Clearsight during awake carotid endarterectomy: A prospective observational study. Eur J Anaesthesiol 2019; 36:144-152. [PMID: 30562226 DOI: 10.1097/eja.0000000000000938] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Continuous noninvasive blood pressure (CNBP) measurement using the volume-clamp method is a less invasive alternative compared with invasive intra-arterial monitoring for awake patients during carotid endarterectomy (CEA) under regional anaesthesia. OBJECTIVE We investigated the agreement of blood pressure (BP) recorded with invasive and CNBP methods during awake CEA. DESIGN A prospective observational study for assessing agreement with Bland-Altman plots, agreement-tolerability indices (ATI), concordance and interchangeability. SETTING Azienda Ospedaliera Universitaria G. Martino, Messina, a University tertiary referral centre in Italy. PATIENTS In 30 consecutive patients, we recorded continuously ipsilateral invasive and noninvasive BPs, from 3 min before carotid cross-clamping to 5 min after unclamping. MAIN OUTCOME MEASURES Primary outcome was bias, 95% limits of agreement, ATI, concordance and interchangeability for mean arterial pressure (MAP). Secondary outcomes were agreements for systolic arterial pressure and diastolic arterial pressure. Tracking of changes was assessed with four-quadrant polar plots and the trend interchangeability method. Optimal bias was defined as 5 mmHg or less. RESULTS A total of 2672 invasive and CNBP paired measurements (93% of overall data) were analysed, with a median of 92 readings per patient [IQR 76 to 100]. Mean (SD) bias for MAP, systolic arterial pressure and DAP were -6.8 (6.7), -3.0 (9.7) and -9.0 (5.4) mmHg, respectively. The ATIs were 0.88, 0.95 and 0.71, respectively, where ATI of 1.0 or less and at least 2.0 defined acceptable, marginal and unacceptable agreements. The four-quadrant plot analysis for beat-to-beat differences showed concordance rates of 97.3%, 99.98% and 96.4%, respectively. Polar plot analysis showed 95% limits of agreement of -3 to 3, -2 to 2 and -2 to 2 mmHg respectively. Trend interchangeability method showed an interchangeability rate of 95% for MAP. CONCLUSION During CEA performed under regional anaesthesia, CNBP offers a less invasive approach for BP monitoring. We found acceptable agreement for MAP defined by an ATI of 0.88 and an excellent 95% global interchangeability rate. A suboptimal bias of 7 mmHg was found with CNBP for MAP.
Collapse
|
27
|
Harky A, Chan JSK, Kot TKM, Sanli D, Rahimli R, Belamaric Z, Ng M, Kwan IYY, Bithas C, Makar R, Chandrasekar R, Dimitri S. General Anesthesia Versus Local Anesthesia in Carotid Endarterectomy: A Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth 2019; 34:219-234. [PMID: 31072705 DOI: 10.1053/j.jvca.2019.03.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 03/13/2019] [Accepted: 03/14/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The choice of anesthetic technique in carotid endarterectomy (CEA) has been controversial. This study compared the outcomes of general anesthesia (GA) and local anesthesia (LA) in CEA. DESIGN Systematic review and meta-analysis of comparative studies. SETTING Hospitals. PARTICIPANTS Adult patients undergoing CEA with either LA or GA. INTERVENTIONS The effects of GA and LA on CEA outcomes were compared. MEASUREMENTS AND MAIN RESULTS PubMed, OVID, Scopus, and Embase were searched to June 2018. Thirty-one studies with 152,376 patients were analyzed. A random effect model was used, and heterogeneity was assessed with the I2 and chi-square tests. LA was associated with shorter surgical time (weighted mean difference -9.15 min [-15.55 to -2.75]; p = 0.005) and less stroke (odds ratio [OR] 0.76 [0.62-0.92]; p = 0.006), cardiac complications (OR 0.59 [0.47-0.73]; p < 0.00001), and in-hospital mortality (OR 0.72 [0.59-0.90]; p = 0.003). Transient neurologic deficit rates were similar (OR 0.69 [0.46-1.04]; p = 0.07). Heterogeneity was significant for surgical time (I2 = 0.99, chi-square = 1,336.04; p < 0.00001), transient neurologic deficit (I2 = 0.41, chi-square = 28.81; p = 0.04), and cardiac complications (I2 = 0.42, chi-square = 43.32; p = 0.01) but not for stroke (I2 = 0.22, chi-square = 30.72; p = 0.16) and mortality (I2 = 0.00, chi-square = 21.69; p = 0.65). Randomized controlled trial subgroup analysis was performed, and all the aforementioned variables were not significantly different or heterogenous. CONCLUSION The results from this study showed no inferiority of using LA to GA in patients undergoing CEA. Future investigations should be reported more systematically, preferably with randomization or propensity-matched analysis, and thus registries will facilitate investigation of this subject. Anesthetic choice in CEA should be individualized and encouraged where applicable.
Collapse
Affiliation(s)
- Amer Harky
- Department of Vascular Surgery, Countess of Chester, Chester, United Kingdom.
| | - Jeffrey Shi Kai Chan
- Faculty of Medicine, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Thompson Ka Ming Kot
- Faculty of Medicine, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | | | - Rashad Rahimli
- Faculty of Medicine, Bulent Ecevit University, Zonguldak, Turkey
| | - Zlatka Belamaric
- Department of Perioperative Medicine, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Marcus Ng
- Faculty of Medicine, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Ian Yu Young Kwan
- Faculty of Medicine, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Christiana Bithas
- School of Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Ragai Makar
- Department of Vascular Surgery, Countess of Chester, Chester, United Kingdom
| | | | - Sameh Dimitri
- Department of Vascular Surgery, Countess of Chester, Chester, United Kingdom
| |
Collapse
|
28
|
Lee J, Lee S, Kim SW, Chang JW. Selective Shunting Based on Dual Monitoring with Electroencephalography and Stump Pressure for Carotid Endarterectomy. Vasc Specialist Int 2018; 34:72-76. [PMID: 30310810 PMCID: PMC6175570 DOI: 10.5758/vsi.2018.34.3.72] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 07/14/2018] [Accepted: 08/07/2018] [Indexed: 11/20/2022] Open
Abstract
Purpose The aim of this study is to analyze postoperative outcomes for carotid endarterectomy (CEA) in addition to the preoperative clinical characteristics related to selective shunting based on dual monitoring with stump pressure (SP) and electroencephalography (EEG). Materials and Methods We retrospectively reviewed medical records of 70 patients who underwent CEA from March 2010 to December 2017. CEA was performed under general anesthesia and selective shunting was done if the SP was lower than 35 mmHg regardless of EEG or if intraoperative EEG showed any changes different from preoperative one regardless of SP. Results There was no postoperative 30-day adjusted mortality or adverse cardiac events. Three patients (4.3%) had postoperative minor stroke finally reaching pre-operative neurologic status at the time of discharge. Twenty-six patients (37.1%) used shunting and severe contralateral internal carotid stenosis or occlusion was related to shunting (P<0.010). There were larger number of symptomatic patients in shunt group in spite of no statistical significance (P=0.116). Conclusion Perioperative stroke rate was 4.3% for CEA under general anesthesia based on dual intraoperative monitoring with SP and EEG. There was no 30-day adjusted mortality and adverse cardiac event. Severe stenosis or occlusion of contralateral internal carotid artery is related to shunting (P<0.010).
Collapse
Affiliation(s)
- Jonggeun Lee
- Department of Thoracic and Cardiovascular Surgery, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Seogjae Lee
- Department of Thoracic and Cardiovascular Surgery, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Su Wan Kim
- Department of Thoracic and Cardiovascular Surgery, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Jee Won Chang
- Department of Thoracic and Cardiovascular Surgery, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| |
Collapse
|
29
|
Do W, Cho AR, Kim EJ, Kim HJ, Kim E, Lee HJ. Ultrasound-guided superficial cervical plexus block under dexmedetomidine sedation versus general anesthesia for carotid endarterectomy: a retrospective pilot study. Yeungnam Univ J Med 2018; 35:45-53. [PMID: 31620570 PMCID: PMC6784676 DOI: 10.12701/yujm.2018.35.1.45] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 03/28/2018] [Accepted: 04/09/2018] [Indexed: 11/04/2022] Open
Abstract
Background Carotid endarterectomy (CEA) has been performed under regional and general anesthesia (GA). The general anesthesia versus local anesthesia for carotid surgery study compared the two techniques and concluded that there was no difference in perioperative outcomes. However, since this trial, new sedative agents have been introduced and devices that improve the delivery of regional anesthesia (RA) have been developed. The primary purpose of this pilot study was to compare intraoperative hemodynamic stability and postoperative outcomes between GA and ultrasound-guided superficial cervical plexus block (UGSCPB) under dexmedetomidine sedation for CEA. Methods Medical records from 43 adult patients who underwent CEA were retrospectively reviewed, including 16 in the GA group and 27 in the RA group. GA was induced with propofol and maintained with sevoflurane. The UGSCPB was performed with ropivacaine under dexmedetomidine sedation. We compared the intraoperative requirement for vasoactive drugs, postoperative complications, pain scores using the numerical rating scale, and the duration of hospital stay. Results There was no difference between groups in the use of intraoperative antihypertensive drugs. However, intraoperative inotropic and vasopressor agents were more frequently required in the GA group (p<0.0001). In the GA group, pain scores were significantly higher during the first 24 h after surgery (p<0.0001 between 0-6 h, p<0.004 between 6-12 h, and p<0.001 between 12-24 h). The duration of hospital stay was significantly more in the GA group (13.3±4.6 days in the GA group vs. 8.5±2.4 days in the RA group, p<0.001). Conclusion In this pilot study, intraoperative hemodynamic stability and postoperative outcomes were better in the RA compared to the GA group.
Collapse
Affiliation(s)
- Wangseok Do
- Department of Anesthesia and Pain Medicine, Pusan National University, School of Medicine, Busan, Korea
| | - Ah-Reum Cho
- Department of Anesthesia and Pain Medicine, Pusan National University, School of Medicine, Busan, Korea
| | - Eun-Jung Kim
- Department of Dental Anesthesia and Pain Medicine, Pusan National University Dental Hospital, Dental Research Institute, Yangsan, Korea
| | - Hyae-Jin Kim
- Department of Anesthesia and Pain Medicine, Pusan National University, School of Medicine, Busan, Korea
| | - Eunsoo Kim
- Department of Anesthesia and Pain Medicine, Pusan National University, School of Medicine, Busan, Korea
| | - Heon-Jeong Lee
- Department of Anesthesia and Pain Medicine, Pusan National University, School of Medicine, Busan, Korea
| |
Collapse
|
30
|
Valentine EA, Zhou EY, Gordon EK, Ochroch EA. The Year in Vascular Anesthesia: Selected Highlights From 2017. J Cardiothorac Vasc Anesth 2018; 32:2043-2053. [PMID: 29784496 DOI: 10.1053/j.jvca.2018.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Elizabeth A Valentine
- Department of Anesthesiology and Critical Care, Division of Cardiovascular and Thoracic Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA.
| | - Elizabeth Y Zhou
- Department of Anesthesiology and Critical Care, Division of Cardiovascular and Thoracic Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Emily K Gordon
- Department of Anesthesiology and Critical Care, Division of Cardiovascular and Thoracic Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - E Andrew Ochroch
- Department of Anesthesiology and Critical Care, Division of Cardiovascular and Thoracic Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA
| |
Collapse
|