Local Anaesthesia in Carotid Surgery: A Prospective Study of III Endarterectomies in 100 Patients

Scandinavian journal of thoracic and cardiovascular surgery 02/1984; 18(2):133-7. DOI: 10.3109/14017438409102393
Source: PubMed


A prospective study was carried out on 100 patients consecutively undergoing carotid endarterectomy in local anaesthesia, in order to evaluate the usefulness of clinical signs in awake patients for monitoring of cerebral function and to determine the need for internal shunt in carotid surgery. The indications for operations were transient ischemic attacks in 67 patients and major or minor stroke in 24 (16 with persistent neurologic deficit). In nine asymptomatic patients the endarterectomy was prophylactic, following detection of bruit and angiographic stenosis. Bilateral stenosis was present in 47 patients, including 13 with total occlusion of the contralateral vessel, and 60 patients had significant vertebral artery stenosis. The carotid artery was first tentatively occluded and, if this was well tolerated for 5 min, endarterectomy was done without an internal shunt. Neurologic deficit signs during the trial occlusion necessitated such shunt in 16 patients with pressure in the internal carotid stump ranging from 0 to 40 (mean 22.4) mmHg. On the other hand, 11 additional patients with stump pressure less than 35 mmHg tolerated the trial occlusion well, underwent carotid endarterectomy without internal shunt and had no deficit symptoms during or after operation. One patient died postoperatively. Hemiparesis appeared in two more patients, but resolved completely in one and gave only minor sequelae in the other. These complications were related to the preoperative condition (stroke) and the postoperative residual pressure gradient. It is concluded that trial occlusion of the carotid artery and observation of the awake patient provide reliable information on the need for an internal shunt during carotid endarterectomy.

1 Read
  • [Show abstract] [Hide abstract]
    ABSTRACT: Forty-one variables were examined in 75 patients who underwent carotid endarterectomy to determine if significant differences were present between 45 patients who had general anesthesia and 30 patients who had regional anesthesia. The two groups were similar in terms of age, existing medical illnesses, neurologic presentation, and angiographic severity of the carotid lesions. There were no differences between the two groups for operative time, anesthesia time, blood loss, maximum or minimum blood pressures, postoperative hemodynamic data, or the requirement for or duration of intravenous pressor or antihypertensive medications. One patient in the regional group had a postoperative neurologic deficit which resolved in 1 month. Three patients in the general group had cardiovascular complications. Postoperative hospital stay was significantly longer in the general anesthesia group (5.6 to 3.2 days, p = 0.003). Regional and general anesthesia produce similar perioperative hemodynamic and surgical outcomes, but regional anesthesia results in a shorter hospital stay and less cardiovascular morbidity in this high risk population.
    No preview · Article · Jan 1987 · The American Journal of Surgery
  • [Show abstract] [Hide abstract]
    ABSTRACT: A randomised, prospective study was performed to compare local (LA) and general anaesthesia (GA) in carotid surgery with special emphasis on complications and the need for intra-operative shunting. Fifty-six patients were randomised to LA and 55 to GA. Eight patients in the LA group required a GA for various reasons. During the same period 14 patients were not randomised. Seven perioperative neurological deficits occurred (5.6%), four in the LA group, two in the GA group, and one in the non-randomised group (NS). Selective shunting was used, in the Ga group according to stump pressure or in cases with a previous stroke and in the LA group according to the appearance of neurological symptoms. In the GA group 25 patients were shunted and in the LA group five patients (P less than 0.001) needed a shunt. If strict pressure criteria for shunting had been used in the LA patients, ten would have been shunted and three of the patients who developed symptoms during clamping would not have been shunted. During surgery the highest recorded systolic pressure was significantly higher in the LA group (210 mmHg versus 173 mmHg, P less than 0.001). LA for carotid endarterectomy is comparable with general anaesthesia regarding peroperative complications but produces significantly higher blood pressures than general anaesthesia. On the other hand it allows the possibility of neurologic monitoring of the patient and leads to significantly less use of an intra-operative shunt.
    No preview · Article · Jan 1990 · European Journal of Vascular Surgery
  • [Show abstract] [Hide abstract]
    ABSTRACT: 30 patients with a history of transient ischemic attacks (TIA) and 16 patients with cerebral infarcts were evaluated neuropsychologically 1-3 days before carotid endarterectomy, due to hemodynamically significant carotid artery stenosis, and again 2 weeks and 2 months after operation. Preoperatively, there were no differences between the groups, but postoperatively the neuropsychological outcome of the TIA patients was better than that of the infarction patients. Consequently, carotid endarterectomy patients cannot be studied as one group in neuropsychological examinations but various subgroups should be dealt with separately. In the TIA group 2 months after operation, the patients with left-sided operations had improved in verbal but not in visual tests, and the right-operated patients showed improvement also in visual tests. Therefore, the use of sum scores across neuropsychological tests is not preferable in the evaluation of the effects of carotid endarterectomy because after unilateral operation the cognitive improvement is greater in functions ipsilateral to the operation side.
    No preview · Article · Feb 1990 · European Neurology
Show more