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El-Hajj VG, Ghaith AK, Gharios M, El Naamani K, Atallah E, Glener S, Habashy KJ, Hoang H, Sizdahkhani S, Mouchtouris N, Kaul A, Elmi-Terander A, Tjoumakaris S, Gooch MR, Rosenwasser RH, Jabbour P. General Versus Nongeneral Anesthesia for Carotid Endarterectomy: A Prospective Multicenter Registry-Based Study on 25 000 Patients. Neurosurgery 2024; 95:365-371. [PMID: 38391204 DOI: 10.1227/neu.0000000000002887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/05/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Carotid endarterectomy (CEA) is a well-established treatment option for carotid stenosis. The choice between general anesthesia (GA) and nongeneral anesthesia (non-GA) during CEA remains a subject of debate, with concerns regarding perioperative complications, particularly myocardial infarctions. This study aimed to evaluate the outcomes associated with GA vs non-GA CEA using a large, nationwide database. METHODS The National Surgical Quality Improvement Project database was queried for patients undergoing CEA between 2013 and 2020. Primary outcome measures including surgical outcomes and 30-day postoperative complications were compared between the 2 anesthesia methods, after 2:1 propensity score matching. RESULTS After propensity score matching, a total of 25 356 patients (16 904 in the GA and 8452 in the non-GA group) were included. Non-GA compared with GA CEA was associated with significantly shorter operative times (101.9, 95% CI: 100.5-103.3 vs 115.8 95% CI: 114.4-117.2 minutes, P < .001), reduced length of hospital stays (2.3, 95% CI: 2.15-2.4 vs 2.5, 95% CI: 2.4-2.6 days, P < .001), and lower rates of 30-day postoperative complications, including myocardial infarctions (0.8% vs 1.2%, P = .003), unplanned intubations (0.8% vs 1.1%, P = .016), pneumonia (0.5% vs 1%, P < .001), and urinary tract infections (0.4% vs 0.7%, P = .003). These outcomes were notably more pronounced in the younger (≤70 years) and high morbidity (American Society of Anesthesiologists 3-5) cohorts. CONCLUSION In this nationwide registry-based study, non-GA CEA was associated with better short-term outcomes in terms of perioperative complications, compared with GA CEA. The findings suggest that non-GA CEA may be a safer alternative, especially in younger patients and those with more comorbidities.
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Affiliation(s)
| | - Abdul Karim Ghaith
- Department of Neurological Surgery, Mayo Clinic, Rochester , Minnesota , USA
| | - Maria Gharios
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm , Sweden
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Elias Atallah
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Steven Glener
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Karl John Habashy
- Feinberg School of Medicine, Northwestern University, Chicago , Illinois , USA
| | - Harry Hoang
- Department of Neurological Surgery, Mayo Clinic, Rochester , Minnesota , USA
| | - Saman Sizdahkhani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Anand Kaul
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | | | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
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Trystula M, VAN Herzeele I, Kolvenbach R, Tekieli L, Fonteyne C, Mazurek A, Dzierwa K, Chmiel J, Lindsay J, Kwiatkowski T, Hydzik A, Oplawski M, Bederski K, Musialek P. Next-generation transcarotid artery revascularization: TransCarotid flOw Reversal Cerebral Protection And CGUARD MicroNET-Covered Embolic Prevention Stent System To Reduce Strokes - TOPGUARD Study. THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:181-194. [PMID: 39007552 DOI: 10.23736/s0021-9509.24.13121-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
BACKGROUND Stent-assisted carotid artery revascularization employing surgical cutdown for transcervical access and dynamic flow reversal (TCAR) is gaining popularity. TCAR, despite maximized intra-procedural cerebral protection, shows a marked excess of 30-day neurologic complications in symptomatic vs. asymptomatic stenoses. The TCAR conventional single-layer stent (free-cell area 5.89mm2) inability to seal embologenic lesions may be particularly relevant after the flow reversal neuroprotection is terminated. METHODS We evaluated peri-procedural and 30-day major adverse cerebral and cardiac events (MACCE) of TCAR (ENROUTE, SilkRoad Medical) paired with MicroNET-covered neuroprotective stent (CGuard, InspireMD) in consecutive patients at elevated risk of complications with transfemoral/transradial filter-protected stenting (increased lesion-related and/or access-related risk). CGuard (MicroNET free cell area ≈0.02-0.03 mm2) has level-1 evidence for reducing intra- and abolishing post-procedural lesion-related cerebral embolism. RESULTS One hundred and six increased-risk patients (age 72 [61-76] years, median [Q1-Q3]; 60.4% symptomatic, 49.1% diabetic, 36.8% women, 61.3% left-sided index lesion) were enrolled in three vascular surgery centers. Angiographic stenosis severity was 81 (75-91)%, lesion length 21 (15-26)mm, increased-risk lesional characteristics 87.7%. Study stent use was 100% (no other stent types). 74.5% lesions were predilated; post-dilatation rate was 90.6%. Flow reversal duration was 8 (5-11)min. One stroke (0.9%) occurred in an asymptomatic patient prior to establishing neuroprotection (index lesion disruption with the sheath insertion wire); there were no other peri-procedural MACCE. No further adverse events occurred by 30-days. 30-day stent patency was 100% with normal velocities and absence of any in-stent material by Duplex Doppler. CONCLUSIONS Despite a high proportion of increased-risk lesions and clinically symptomatic patients in this study, TCAR employing the MicroNET-covered anti-embolic stent showed 30-day MACCE rate <1%. This suggests a clinical role for combining maximized intra-procedural prevention of cerebral embolism by dynamic flow reversal with anti-embolic stent prevention of peri- and post-procedural cerebral embolism (TOPGUARD NCT04547387).
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Affiliation(s)
- Mariusz Trystula
- Department of Vascular Surgery, St. John Paul II Hospital, Krakow, Poland
| | - Isabelle VAN Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Ralf Kolvenbach
- Department of Vascular Surgery, Sana Kliniken, Düsseldorf, Germany
| | - Lukasz Tekieli
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
| | - Charlotte Fonteyne
- Department of Thoracic and Vascular Surgery, University of Ghent, Ghent, Belgium
| | - Adam Mazurek
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
| | - Karolina Dzierwa
- Cardiovascular Imaging Laboratory, St. John Paul II Hospital, Krakow, Poland
| | - Jakub Chmiel
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
| | | | - Tomasz Kwiatkowski
- Department of Vascular Surgery, St. John Paul II Hospital, Krakow, Poland
| | - Adam Hydzik
- Department of Vascular Surgery, St. John Paul II Hospital, Krakow, Poland
| | | | - Krzysztof Bederski
- Department of Thoracic Surgery, St. John Paul II Hospital, Krakow, Poland
| | - Piotr Musialek
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland -
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
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Mehmedovic A, Tsilimparis N, Stavroulakis K, Rantner B, Fernandez Prendes C, Gouveia E Melo R, Abicht JM, Stana J. Cervical Debranching: Regional versus General Anesthesia for Carotid-Subclavian Bypass. A Single Center Experience. Ann Vasc Surg 2023; 96:132-139. [PMID: 37085013 DOI: 10.1016/j.avsg.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 03/27/2023] [Accepted: 04/01/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND We report here the first cohort study comparing regional and general anaesthesia for left subclavian artery (LSA) revascularization. METHODS A single-centre retrospective cohort study was performed, including all consecutive patients who underwent cervical debranching with carotid-subclavian bypass before aortic repair from February 2018 to May 2022. Patients were divided into 2 groups according to the type of anesthesia: Regional anesthesia (RA) versus general anesthesia (GA). Primary endpoints included the following: 1) technical success of RA and 2) neurological complications (NCs) (stroke and peripheral neurological lesions). Secondary endpoints included postoperative bleeding, wound complications, 30-day reintervention rate, and midterm events. RESULTS Eighty-three patients were included in the study. The mean age was 64 years (interquartile range [IQR]:13.5) and 69% were male. Thirty-seven patients (44.5%) were performed under RA. Technical success of RA was 89.2%. Two minor strokes (2.4%) were observed in the GA group (P = 0.199). Peripheral neurological disorders occurred in 4 patients (4.8%) (RA group n = 1 (2.7%), GA group n = 3 (6.5%), P = 0.491). 30-day complication rate was 27.7% (n = 23, GA: n = 15 (32.6%), RA: n = 8 (21.6%), P = 0.266). 30-day reintervention rate was 14.5% (n = 12) ten bleeding complications (12%) (RA group n = 3 (8.1%), GA group n = 7 (15.2%), P = 0.323), and 2 seroma evacuations (2.4%) in the RA group. The incidence of superficial wound infections was n = 6 (7.2%) (RA group n = 2 (5.4%), GA group n = 4 (8.7%), P = 0.565). Median follow-up time was 22 months (IQR 22 min/max 1-44). CONCLUSIONS In our cohort, RA for carotid subclavian bypass surgery proved to be a feasible and effective anesthetic procedure compared with GA.
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Affiliation(s)
- Aldin Mehmedovic
- Vascular Surgery Department, Ludwig Maximilian University Hospital, Munich, Germany
| | - Nikolaos Tsilimparis
- Vascular Surgery Department, Ludwig Maximilian University Hospital, Munich, Germany.
| | | | - Barbara Rantner
- Vascular Surgery Department, Ludwig Maximilian University Hospital, Munich, Germany
| | | | - Ryan Gouveia E Melo
- Vascular Surgery Department, Ludwig Maximilian University Hospital, Munich, Germany
| | - Jan-Michael Abicht
- Anesthesiology Department, Ludwig Maximilian University Hospital, Munich, Germany
| | - Jan Stana
- Vascular Surgery Department, Ludwig Maximilian University Hospital, Munich, Germany
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Leblanc I, Chterev V, Rekik M, Boura B, Costanzo A, Bourel P, Combes M, Philip I. Safety and efficiency of ultrasound-guided intermediate cervical plexus block for carotid surgery. Anaesth Crit Care Pain Med 2016; 35:109-14. [DOI: 10.1016/j.accpm.2015.08.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 07/15/2015] [Accepted: 08/11/2015] [Indexed: 11/16/2022]
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Papapetrou A, Moris D, Patelis N, Kouvelos GN, Bakogiannis C, Klonaris C, Georgopoulos S. Oxidative Stress and Total Antioxidant Status During Internal Carotid Artery Clamping with or without Shunting: An Experimental Pilot Study. Med Sci Monit Basic Res 2015; 21:200-5. [PMID: 26391530 PMCID: PMC4596353 DOI: 10.12659/msmbr.894756] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background The exact role of shunting during carotid endarterectomy remains controversial and unclear. The aim of this experimental study was to investigate to what degree carotid clamping may induce changes in the cerebral oxidative status and to focus on the relation of these changes with shunt insertion. Material/Methods Forty New-Zealand rabbits were randomized into 4 groups: group 1 classifying animals with carotid shunt and patent contralateral carotid artery; group 2 shunt and occlusion of the contralateral carotid artery; group 3 no-shunt and patent contralateral carotid artery; and group 4 no-shunt and occlusion of the contralateral carotid artery. Blood samples were collected from the ipsilateral internal jugular vein, immediately after carotid clamping (time 0), and then at 5, 10, 15, 30, and 60 minutes afterwards. Evaluation of oxidative stress was accomplished by measuring the lag-time, representing the initial phase of oxidation, rate of accumulation (RA), showing concentration of free oxygen radical and total antioxidant status (TAS) representing antioxidant composition of serum. Results Lag-time was significantly different in time points 0, 30 and 60 minutes within each different group. TAS was significantly different in time points 0, 15 and 60 min and RA in time points 0, 5, 10 and 60 min within each different group. 60 minutes after carotid clamping, the rate of accumulation as well as lag-time and TAS were increased in all groups, independently of using or not shunting or the presence of contralateral occlusion. After comparing groups 1, 2 and 3 regarding lag-time, TAS and RA, we did not find statistical difference among the groups at any time point. On the contrary, groups 1, 2 and 3 did show significantly different values comparing to group 4 after 60 min of occlusion. Conclusions Our experimental work based on cerebral metabolism found a significantly higher oxidative stress in models with contralateral carotid occlusion. The use of shunt in all other models did not have any influence on oxidative response. Future human studies should focus on the relation of oxidative status and shunt insertion to determine the benefit of selective or routine shunting during CEA.
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Affiliation(s)
- Anastasios Papapetrou
- 1st Department of Surgical, Vascular Division, Laikon General Hospital, National Kapodistrian University of Athens, Athens, Greece
| | - Demetrios Moris
- 1st Department of Surgical, Vascular Division, Laikon General Hospital, National Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Patelis
- 1st Department of Surgical, Vascular Division, Laikon General Hospital, National Kapodistrian University of Athens, Athens, Greece
| | - George N Kouvelos
- 1st Department of Surgical, Vascular Division, Laikon General Hospital, National Kapodistrian University of Athens, Athens, Greece
| | - Chris Bakogiannis
- 1st Department of Surgical, Vascular Division, Laikon General Hospital, National Kapodistrian University of Athens, Athens, Greece
| | - Chris Klonaris
- 1st Department of Surgical, Vascular Division, Laikon General Hospital, National Kapodistrian University of Athens, Athens, Greece
| | - Sotiris Georgopoulos
- 1st Department of Surgical, Vascular Division, Laikon General Hospital, National Kapodistrian University of Athens, Athens, Greece
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Kessler J, Marhofer P, Hopkins P, Hollmann M. Peripheral regional anaesthesia and outcome: lessons learned from the last 10 years. Br J Anaesth 2015; 114:728-45. [DOI: 10.1093/bja/aeu559] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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Abstract
Summary Regional anaesthesia is a popular choice for patients undergoing carotid endarterectomy (CEA). Neurological function is easily assessed during carotid cross-clamping; haemodynamic control is predictable; and hospital stay is consistently shorter compared with general anaesthesia (GA). Despite these purported benefits, mortality and stroke rates associated with CEA remain around 5% for both regional anaesthesia and GA. Regional anaesthetic techniques for CEA have improved with improved methods of location of peripheral nerves including nerve stimulators and ultrasound together with a modification in the classification of cervical plexus blocks. There have also been improvements in local anaesthetic, sedative, and arterial pressure-controlling drugs in patients undergoing CEA, together with advances in the management of patients who develop neurological deficit after carotid cross-clamping. In the UK, published national guidelines now require the time between the patient's presenting neurological event and definitive treatment to 1 week or less. This has implications for the ability of vascular centres to provide specialized vascular anaesthetists familiar with regional anaesthetic techniques for CEA. Providing effective regional anaesthesia for CEA is an important component in the armamentarium of techniques for the vascular anaesthetist in 2014.
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Affiliation(s)
- M D Stoneham
- Nuffield Division of Anaesthetics, Level 2, Oxford University Hospitals NHS Trust, Headley Way, Oxford OX3 9DU, UK
| | - D Stamou
- Nuffield Division of Anaesthetics, Level 2, Oxford University Hospitals NHS Trust, Headley Way, Oxford OX3 9DU, UK
| | - J Mason
- Nuffield Division of Anaesthetics, Level 2, Oxford University Hospitals NHS Trust, Headley Way, Oxford OX3 9DU, UK
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Cerebral monitors versus regional anesthesia to detect cerebral ischemia in patients undergoing carotid endarterectomy: a meta-analysis. Can J Anaesth 2013; 60:266-79. [DOI: 10.1007/s12630-012-9876-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 12/18/2012] [Indexed: 10/27/2022] Open
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Atkinson CJ, Ramaswamy K, Stoneham MD. Regional anesthesia for vascular surgery. Semin Cardiothorac Vasc Anesth 2013; 17:92-104. [PMID: 23327951 DOI: 10.1177/1089253212472985] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Vascular surgical patients are a diverse group of patients who tend to be elderly, with multiple comorbidities, while vascular procedures may involve significant blood loss and ischemia of tissues beyond the arterial obstruction. Regional anesthesia techniques may offer benefits to patients undergoing vascular surgery because of their cardiorespiratory comorbidities. However, this group of patients is commonly receiving multiple medications, including anticoagulants, so regional techniques are not without risks. This review will discuss this topic based around 3 fundamental revascularization procedures, carotid, abdominal aortic aneurysm repair, and infrainguinal surgery, discussing the clinical applications of regional techniques relevant to each key area.
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Guay J, Ochroch EA. Carotid endarterectomy plus medical therapy or medical therapy alone for carotid artery stenosis in symptomatic or asymptomatic patients: a meta-analysis. J Cardiothorac Vasc Anesth 2012; 26:835-44. [PMID: 22494782 DOI: 10.1053/j.jvca.2012.01.044] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The purpose of this study was to compare carotid endarterectomy (CEA) plus medical therapy (MT) with MT alone for symptomatic and asymptomatic patients suffering from carotid artery stenosis in terms of long-term stroke/death rate. DESIGN A meta-analysis of parallel randomized, controlled trials (RCTs) (blind or open) published in English. SETTING A university-based electronic search. PARTICIPANTS Patients suffering from carotid artery stenosis symptomatic or not. INTERVENTIONS Patients were subjected to CEA plus MT or MT alone. MEASUREMENTS AND MAIN RESULTS For asymptomatic patients, 6 RCTs comprising 5,733 patients (CEA = 2,853 and MT = 2,880) were included. CEA did not affect the stroke/death risk for asymptomatic patients (risk ratio [RR] = 0.93; 95% confidence interval [CI], 0.84 to 1.02; I(2) = 0%; p = 0.14). For symptomatic patients, 2 RCTs were included. They had 5,627 patients (CEA = 3,069 and MT = 2,558) of whom 2,295 patients (CEA = 1,213; MT = 1,082) had severe stenosis (North American Symptomatic Carotid Endarterectomy Trial [NASCET] technique ≥50% and European Carotid Surgery Trial technique ≥70%). CEA decreased the stroke/death risk only for patients with severe stenosis (RR = 0.69; 95% CI, 0.59-0.81; p < 0.001 [random effects model]; I(2) = 0% on the odds ratio and 17% on the RR [benefit or harm side]; number needed to treat = 11 [95% CI, 8-17]). CONCLUSIONS CEA is helpful for recently symptomatic patients with carotid artery stenosis ≥50% (NASCET technique) but adds no benefit in terms of stroke/death for asymptomatic patients.
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Affiliation(s)
- Joanne Guay
- Department of Anesthesiology, University of Montréal, Montreal, Quebec, Canada.
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Carotid endarterectomy in the acute phase of stroke-in-evolution is safe and effective in selected patients. J Vasc Surg 2012; 55:701-7. [PMID: 22070936 DOI: 10.1016/j.jvs.2011.09.054] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Revised: 09/12/2011] [Accepted: 09/13/2011] [Indexed: 11/22/2022]
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Gürer O, Yapıcı F, Yapıcı N, Özler A, Işık Ö. Comparison Between Local and General Anesthesia for Carotid Endarterectomy: Early and Late Results. Vasc Endovascular Surg 2012; 46:131-8. [DOI: 10.1177/1538574411431345] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The aim of this retrospective study was to compare the results between general and local anesthesia (LA) for carotid endarterectomy (CEA). Methods: Three hundred and twenty-nine patients in whom 365 CEA procedures were performed between January 1990 and September 2001, were included in this study. Results: Operation time, shunt usage rates, hospitalization time ( P < .0001), and permanent stroke rates ( P < .05) were significantly lower in group with LA. For long-term period (121.3 ± 37.45 vs 98.6 ± 28.98 months), no significant difference was observed in these 2 group with respect to restenosis rates, neurological events, and deaths. Conclusions: Despite the lack of significant difference between LA and general anesthesia in terms of restenosis, neurological events, and death in the long-term period; LA is more preferable due its associated advantages including availability of testing the consciousness of the patients by direct contact, reduced use of shunts, shorter hospitalization periods, and less prevalence of permanent stroke in the short-term period.
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Affiliation(s)
- Onur Gürer
- Department of Cardiovascular Surgery, Medicana Hospitals Çamlıca, İstanbul, Turkey
| | - Fikri Yapıcı
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Center, Istanbul, Turkey
| | - Nihan Yapıcı
- Department of Anesthesiology, Siyami Ersek Thoracic and Cardiovascular Surgery Center, İstanbul, Turkey
| | - Azmi Özler
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Center, Istanbul, Turkey
| | - Ömer Işık
- Department of Cardiovascular Surgery, Medicana Hospitals Çamlıca, İstanbul, Turkey
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Guay J. Endovascular Stenting or Carotid Endarterectomy for Treatment of Carotid Stenosis: A Meta-analysis. J Cardiothorac Vasc Anesth 2011; 25:1024-9. [DOI: 10.1053/j.jvca.2011.01.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2010] [Indexed: 11/11/2022]
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Ramachandran SK, Picton P, Shanks A, Dorje P, Pandit JJ. Comparison of intermediate vs subcutaneous cervical plexus block for carotid endarterectomy. Br J Anaesth 2011; 107:157-63. [PMID: 21613278 DOI: 10.1093/bja/aer118] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Carotid endarterectomy surgery can be performed under regional anaesthesia alone or under general anaesthesia. However, there are several types of regional block available and reported complication rates after superficial cervical plexus blocks are significantly lower than deep blocks. It is not known if subcutaneous and intermediate blocks are equally effective, although anatomical evidence suggests that the latter (where the injectate diffuses below the deep cervical fascia) might provide superior quality of intraoperative anaesthesia. METHODS Forty-four patients were randomized to receive either subcutaneous or intermediate cervical plexus blocks for carotid endarterectomy. The primary endpoint was supplemental lidocaine requirement during surgery. Secondary outcome measures included: total amount of fentanyl administered during surgery, recall of pain scores during surgery, complications, and patient and surgeon satisfaction. RESULTS There was no statistically significant difference for median (range) lidocaine supplementation between the subcutaneous and intermediate groups 65 (20-170) mg vs. 85 (30-345) mg, respectively; P=0.31. There were no statistical differences in the secondary outcome measures and no major complications during the study. CONCLUSIONS Intermediate and subcutaneous cervical plexus blocks are equally effective for carotid endarterectomy. This study adds to the body of evidence supporting the safe use of superficial blocks for this type of surgery.
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Affiliation(s)
- S K Ramachandran
- Department of Anesthesiology, University of Michigan Medical School, 1 H427 University Hospital P.O. Box 0048, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0048, USA.
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Attigah N, Kutter J, Demirel S, Hakimi M, Hinz U, Motsch J, Böckler D. Assessment of Patients’ Satisfaction in Carotid Surgery under Local Anaesthesia by Psychometrical Testing – A Prospective Cohort Study. Eur J Vasc Endovasc Surg 2011; 41:76-82. [DOI: 10.1016/j.ejvs.2010.08.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Accepted: 08/20/2010] [Indexed: 10/19/2022]
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Subclinical neurocognitive dysfunction after carotid endarterectomy-the impact of shunting. J Neurosurg Anesthesiol 2010; 22:195-201. [PMID: 20479673 DOI: 10.1097/ana.0b013e3181d5e421] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Subclinical neurocognitive deficit after carotid endarterectomy (CEA) has been reported in 25% of patients. The influence of the type of anesthesia and shunting on early postoperative neurocognitive function remains unclear. Therefore, we analyzed the cognitive function after CEA using a battery of psychometric tests before surgery and on the first postoperative day. METHODS Twenty nine patients under regional and 28 under general anesthesia were included in the study. Regional anesthesia was administered inducing a superficial cervical block, and the general anesthesia was induced using a standardized manner. Then cognitive function was tested using a battery of psychometric tests before and 24 hours after surgery. S 100 beta was determined at the same time points. RESULTS A statistical difference was found between the results of the testing before and after CEA: decline in digit symbol test (9%), perceptual speed (6%), and spatial working memory (44%) and improvement in verbal fluency (6%) and attention (5%). The only intraoperative factor that correlated with the cognitive dysfunction was shunt insertion; patients with a shunt had a lower perceptual speed (P=0.005) and worse spatial working memory (P=0.004). No correlation was found between the type of anesthesia or S 100 beta level and any psychometric test, but these results might be influenced by the small sample size in our study. CONCLUSIONS Shunt insertion was the only parameter correlated with cognitive decline on the first day after CEA. Regional anesthesia might offer indirect benefit because of a reduced need of shunting in wakeful patients. Larger studies are required to clarify the role of shunting and type of anesthesia in early neurocognitive deficit after CEA and its impact on the quality of life.
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Paraskevas KI, Mikhailidis DP, Veith FJ. Are Symptomatic Patients Appropriate Candidates For Carotid Artery Stenting? No (at Least Not At Present). Vascular 2010; 18:185-8. [DOI: 10.2310/6670.2010.00027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Most symptomatic patients should not be candidates for carotid artery stenting (CAS); at least not at present. In these patients, CAS is associated with higher stroke, as well as recurrent stenosis rates compared with carotid endarterectomy (CEA). Furthermore, CAS is considerably more expensive than CEA. These facts raise the question, why perform CAS in symptomatic patients when you have CEA, which is associated with lower stroke and recurrent stenosis rates, and is also a more cost-effective option. This article supports the theory that currently most symptomatic patients are not appropriate candidates for CAS.
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Affiliation(s)
- Kosmas I. Paraskevas
- *Department of Vascular Surgery, Red Cross Hospital, Athens, Greece; †Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus, University College Medical School, University College London, London, UK; ‡Department of Vascular Surgery, The Cleveland Clinic and New York University Medical Center, New York, NY
| | - Dimitri P. Mikhailidis
- *Department of Vascular Surgery, Red Cross Hospital, Athens, Greece; †Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus, University College Medical School, University College London, London, UK; ‡Department of Vascular Surgery, The Cleveland Clinic and New York University Medical Center, New York, NY
| | - Frank J. Veith
- *Department of Vascular Surgery, Red Cross Hospital, Athens, Greece; †Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus, University College Medical School, University College London, London, UK; ‡Department of Vascular Surgery, The Cleveland Clinic and New York University Medical Center, New York, NY
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Lactate flux during carotid endarterectomy under general anesthesia: correlation with various point-of-care monitors. Can J Anaesth 2010; 57:903-12. [DOI: 10.1007/s12630-010-9356-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Accepted: 07/01/2010] [Indexed: 10/19/2022] Open
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Perioperative outcome of carotid endarterectomy with regional anesthesia: two decades of experience from the Caribbean. J Clin Anesth 2010; 22:169-73. [DOI: 10.1016/j.jclinane.2009.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2008] [Revised: 04/28/2009] [Accepted: 05/19/2009] [Indexed: 11/19/2022]
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Bodenham A, Howell S. General anaesthesia vs local anaesthesia: an ongoing story. Br J Anaesth 2009; 103:785-9. [DOI: 10.1093/bja/aep310] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Paraskevas KI, Mikhailidis DP, Bell PR. The GALA Trial: Will It Influence Clinical Practice? Vasc Endovascular Surg 2009; 43:429-32. [DOI: 10.1177/1538574409340589] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The General Anesthesia vs. Local Anesthesia for Carotid Surgery (GALA) trial did not show a difference in 30-day postoperative stroke, myocardial infarction and death rates between patients undergoing carotid endarterectomy (CEA) under local vs. general anesthesia. The present article discusses some limitations of the GALA trial. Firstly, the expected stroke and death rates following CEA is so low, that it was unlikely that the GALA trial would show any significant difference between local and general anesthesia. Secondly, preoperative statin use was not recorded. Thirdly, intraoperative shunt usa ge rates (a possible parameter for the development of stroke) varied considerably between the 2 groups (43% vs. 14%, for general vs. local anesthesia, respectively; P < .0001), as well as between UK and non-UK surgeons who always (73.6% vs. 20.8%, respectively; P < .0001), never (4.2% vs. 26%, respectively; P < .0002), or selectively (22.2% vs. 53.2%, respectively; P < .0001) used a shunt. Furthermore, no information was provided regarding the type of shunts used; for example, atraumatic shunts may be associated with lower perioperative stroke rates. These limitations could influence the interpretation of the results of the GALA trial. Due to lack of differences between the 2 groups and the presence of the above limitations, it seems likely that this trial will have little effect on clinical practice.
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Affiliation(s)
| | - Dimitri P. Mikhailidis
- Department of Clinical Biochemistry (Vascular Disease Prevention Clinic), Royal Free Hospital Campus, University College London (UCL), University of London, London, United Kingdom,
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