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Padmanaban V, Caldwell C, Milne I, Hazard SW, Harbaugh RE, Church EW. Carotid endarterectomy using regional anesthesia: technique and considerations. Front Surg 2024; 11:1421624. [PMID: 38903863 PMCID: PMC11187481 DOI: 10.3389/fsurg.2024.1421624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 05/23/2024] [Indexed: 06/22/2024] Open
Abstract
Background Carotid endarterectomy (CEA) is one of the most effective operations in minimizing stroke risk in both symptomatic and asymptomatic patients with carotid stenosis in the United States. Awake CEA with regional anesthesia may decrease both perioperative complications and length of hospital stay. Techniques of performing awake CEA is not often described in published literature. Objective To describe our experience with CEA using regional anesthesia with a focus on patient selection, anatomic variations, and surgical technique including cervical regional block. We particularly focus on nuances of the awake approach. Methods CEA using regional anesthesia is described in detail. Results Successful use of regional anesthesia during CEA without complication. Conclusion Regional anesthesia for CEA is an advantageous approach for cervical plaque removal in appropriate patients. Thoughtful patient selection, as well as understanding of anatomy and its variants, is required. Potential advantages and disadvantages are discussed.
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Affiliation(s)
- Varun Padmanaban
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Catherine Caldwell
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Indigo Milne
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Sprague W. Hazard
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, United States
- Department of Anesthesia and Perioperative Services, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Robert E. Harbaugh
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Ephraim W. Church
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, United States
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Pereira-Macedo J, Duarte-Gamas L, Pereira-Neves A, de Andrade JJP, Rocha-Neves J. Short-term outcomes after selective shunt during carotid endarterectomy: a propensity score matching analysis. NEUROCIRUGIA (ENGLISH EDITION) 2024; 35:71-78. [PMID: 37696419 DOI: 10.1016/j.neucie.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 07/28/2023] [Indexed: 09/13/2023]
Abstract
INTRODUCTION AND OBJECTIVES Carotid cross-clamping during carotid endarterectomy might lead to intraoperative neurologic deficits, increasing stroke/death risk. If deficits are detected, carotid shunting has been recommended to reduce the risk of stroke. However, shunting may sustain a specific chance of embolic events and subsequently incurring harm. Current evidence is still questionable regarding its clear benefit. The aim is to determine whether a policy of selective shunt impacts the complication rate following an endarterectomy. MATERIAL AND METHODS From January 2013 to May 2021, all patients undergoing carotid endarterectomy under regional anesthesia with intraoperative neurologic alteration were retrieved. Patients submitted to selective shunt were compared to a non-shunt group. A 1:1 propensity score matching (PSM) was performed. Differences between the groups and clinical outcomes were calculated, resorting to univariate analysis. RESULTS Ninety-eight patients were selected, from which 23 were operated on using a shunt. After PSM, 22 non-shunt patients were compared to 22 matched shunted patients. Concerning demographics and comorbidities, both groups were comparable to pre and post-PSM, except for chronic heart failure, which was more prevalent in shunted patients (26.1%, P=0.036) in pre-PSM analysis. Regarding 30-day stroke and score Clavien-Dindo ≥2, no significant association was found (P=0.730, P=0.635 and P=0.942, P=0.472, correspondingly, for pre and post-PSM). CONCLUSIONS In this cohort, resorting to shunting did not demonstrate an advantage regarding 30-day stroke or a Clavien-Dindo ≥ 2 rates. Nevertheless, additional more extensive studies are mandatory to achieve precise results concerning the accurate utility of carotid shunting in this subset of patients under regional anesthesia.
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Affiliation(s)
- Juliana Pereira-Macedo
- Department of Surgery, Centro Hospitalar do Médio-Ave, Vila Nova de Famalicão, Portugal; Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, 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
| | - António Pereira-Neves
- 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; Department of Biomedicine - Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Portugal
| | - José José Paulo de Andrade
- Department of Biomedicine - Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Portugal; Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
| | - João Rocha-Neves
- 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; Department of Biomedicine - Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Portugal
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Rocha-Neves JM, Pereira-Macedo J, Dias-Neto MF, Andrade JP, Mansilha AA. Benefit of selective shunt use during carotid endarterectomy under regional anesthesia. Vascular 2020; 28:505-512. [DOI: 10.1177/1708538120922098] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives Carotid cross-clamping during endarterectomy exposes the patient to intraoperative neurological deficits due to embolism or cerebral hypoperfusion. To prevent further cerebrovascular incidents, resorting to shunt is frequently recommended. However, since this method is also considered a stroke risk factor, the use is still controversial. This study aims to shed some light on the best approach regarding the use of shunt in symptomatic cerebral malperfusion after carotid artery cross-clamping. Methods From January 2012 to January 2018, 79 patients from a tertiary referral hospital who underwent carotid endarterectomy with regional anesthesia for carotid artery stenosis and manifested post-clamping neurologic deficits were prospectively gathered. Shunt use was left to the decision of the surgeon and performed in 31.6% (25) of the patients. Demographics, comorbidities, imaging tests, and clinical/intraoperative features were evaluated. For data assessment, univariate analysis was performed. Results Regarding 30-day stroke, 30-day postoperative complications (stroke, surgical hematoma, hyperperfusion syndrome), and cranial nerve injury, no significant differences were found ( P = 0.301, P = 0.460, and P = 0.301, respectively) between resource to shunt and non-shunt. Clamping and surgery times were significantly higher in the shunt group ( P < 0.001 and P = 0.0001, respectively). Conclusions Selective-shunting did not demonstrate superiority for patients who developed focal deficits regarding stroke or other postoperative complications. However, due to the limitations of this study, the benefit of shunting cannot be excluded. Further randomized trials are recommended for precise results on this matter with current sparse clinical evidence.
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Affiliation(s)
- João M Rocha-Neves
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Biomedicine – Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Department of Physiology and Surgery, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Juliana Pereira-Macedo
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Marina F Dias-Neto
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Physiology and Surgery, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - José Paulo Andrade
- Department of Biomedicine – Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Armando A Mansilha
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Physiology and Surgery, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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Carotid endarterectomy using a "home-constructed" shunt for patients intolerant to cross-clamping. Surg Today 2014; 45:284-9. [PMID: 24748515 DOI: 10.1007/s00595-014-0896-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 02/14/2014] [Indexed: 10/25/2022]
Abstract
PURPOSES There is a small minority of patients with occlusive carotid artery disease, who are at high-risk for general anesthesia because of their intolerance to carotid flow blockage, even if only for seconds, without neurologic deficit. Even <30 s of temporary clamping of the carotid arteries to deploy a shunt may prove eventful in this patient group. We define safe carotid endarterectomy after the insertion of a novel shunt that we made from simple medical equipment in this patient population. METHODS Among 65 patients who underwent carotid endarterectomy between March 2010 and December 2012, 5 (7.7 %; 3 men and 2 women; age range 56-77 years) could not tolerate carotid clamping. We used an alternative carotid shunt, made by us from simple equipment in our clinic, during surgery for these patients. RESULTS Two patients had bilateral lesions and the remainder had unilateral disease. The degree of stenosis ranged from 70 to 95 %. Temporary carotid clamping resulted in neurologic events, such as loss of consciousness in all and tremor in one, in <10 s (range, from immediately to 8 s after clamping). Full neurologic function was regained 15-30 s after releasing the clamps. All of the patients tolerated the procedures well with the support of our novel shunt. Shunt flow was adequate in all patients and no neurologic deterioration occurred after carotid clamping. The mean carotid clamp time was 28.11 ± 14.19 min. There was no mortality and all patients were followed up for a mean period of 9.3 ± 3.6 months, uneventfully. CONCLUSIONS An alternative, simple shunt, which is easily constructed in the operating room or clinic, using an angiocatheter, a three-way stopcock, and a serum line can provide adequate cerebral flow and permit safe carotid endarterectomy for those rare patients with carotid artery stenosis, who cannot tolerate even seconds of carotid occlusion.
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Katano H, Yamada K. Comparison of internal shunts during carotid endarterectomy under routine shunting policy. Neurol Med Chir (Tokyo) 2013; 54:806-11. [PMID: 24305032 PMCID: PMC4533382 DOI: 10.2176/nmc.oa2013-0218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
We compared patients who underwent carotid endarterectomy (CEA) using two-way and three-way internal shunts and discussed which shunt was more appropriate and effective for surgeons. Eighty-two patients (mean 69.5 ± 6.1 years old, mean degrees of stenosis 79.6 ± 10.4%) who had undergone CEA by our routine shunting policy were examined concerning the difference of Sundt and Pruitt-Inahara (P-I) shunts in clinical use. Carotid clamping time for the P-I shunt was over 2 minutes longer than that by Sundt in either split or conventional continuous arteriotomy (p < 0.001). The proportions of cases with multiple trials of either arteriotomy or insertion of a shunt tube, cases detected more than one high-intensity spot on diffusion-weighted images of magnetic resonance imaging after CEA, and cases detected postoperative intimal flaps detected by multi-detector CT angiography showed no significant differences between the two shunt groups. The two-way Sundt shunt was quicker than the three-way P-I shunt in placement with no remarkable problems. Split arteriotomy was not useful in shortening the placement time for either Sundt or P-I shunt tubes, compared with continuous arteriotomy. A simple two-way shunt with easy handling like the Sundt shunt would be also appropriate to choose in selective shunting under the unfamiliarity of treating shunts.
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Affiliation(s)
- Hiroyuki Katano
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Sciences
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Wilhelm M, Klemm K, Assadian A, Schmidli J, Schumacher H, Merrelaar J, Eckstein HH. [Improve your skills!: evaluation of a 2.5-day basic course in vascular surgery for surgical trainees]. Chirurg 2013; 84:125-9. [PMID: 23340973 DOI: 10.1007/s00104-012-2395-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The traditional surgical training in the operating room (OR) is often complemented by participation in workshops and on simulators. The foundation Vascular International offers basic courses for vascular surgery techniques with training on pulsatile circulation, lifelike anatomical models. The aim of this study was to assess the efficacy of a 2.5-day intensive course on basic skills in vascular surgery. MATERIAL AND METHODS A total of 24 participants (67% male with an average age of 35 years) performed a vein patch-plasty before and after the basic vascular surgery instruction course. Endpoints of the study were the time needed for suturing and the technical quality, which were evaluated by two course trainers on a scale of 0-10. Furthermore, the participants were asked to evaluate their own technical competence. The statistical analysis was carried out using MS Excel (t-test and analysis of correlation). RESULTS A significantly shortened time for the suturing (19.5 min versus 14.1 min, p < 0.001) and improved quality of the vein patch were found after the workshop (p < 0.05) with a high correlation between the two observers (r = 0.885). The participants also evaluated their own surgical competence better at the end of the training but there was no correlation between the self-assessment and the quality of the patch (r = 0.146 before and r = 0.109 after the workshop). CONCLUSIONS A significant improvement in the time needed for suturing and the quality of the vein patch-plasty was shown in this study. Further studies are necessary to demonstrate the long-term success and possible shortening of the learning curve in hospitals with professional training. With regard to the current curriculum of surgical trainees in Germany basic vascular surgery courses should be considered as a potential valuable part of the surgical common trunk.
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Affiliation(s)
- M Wilhelm
- Klinik und Poliklinik für Vaskuläre und Endovaskuläre Chirurgie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, München, Deutschland
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Ackerman PD, Loftus CM. Should we adopt micro-interintimal dissection: a novel and worthwhile advance in carotid surgery technique, but does it prevent restenosis and early neurological deficits? World Neurosurg 2013; 82:e87-9. [PMID: 23459277 DOI: 10.1016/j.wneu.2013.02.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Accepted: 02/22/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Paul D Ackerman
- Department of Neurosurgery, Loyola University Stritch School of Medicine, Maywood, Illinois, USA
| | - Christopher M Loftus
- Department of Neurosurgery, Loyola University Stritch School of Medicine, Maywood, Illinois, USA.
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