INTERNAL CAROTID ENDARTERECTOMY UNDER LOCAL ANAESTHESIA
Abstract
Background. Endarterectomy of the internal carotid artery, supported by medicamental treatment, is the best method used to prevent stroke with symptomatic patients with an over 70-percent narrowing of the ipsilateral carotid artery. With patients who have successfully passed the operation the occurrence of the stroke is less often than with non-operated patients (1% vs. 6–10% per year). Therefore, it is important that the operation is carried out as safely as possible. Currently, the average acceptable rate of death and/ or severe stroke risk stands at between 2–4%. Greatest problems faced during carotid artery surgery are embolism of the affected artery during preparation, brain ischaemia during the blockade of the carotid artery, and embolism and intimal tearing due to injury of the internal carotid artery by the temporary internal shunt. Due to the risk of causing an embolism and intimal tearing, the use of the internal shunt can be dangerous. Therefore, selective usage of the shunt is recommended when necessary due to brain ischaemia.
Methods. Under block/conduction anaesthesia (deep and superficial cervical block) we have performed surgery on 23 patients (16 males, 7 females) because of severe stenosis of the internal carotid artery (over 70%). A mixture of Xylocain 1% and Marcain 1.5% was used for the cervical block. Cerebral blood circulation was monitored by neurological testing of the patient awake during the procedure. During the procedure, we performed standard monitoring of the vital functions including the blood pressure. Additionally, the transcranial Doppler monitoring of the blood flow through the middle cerebral artery was used with 20 of the patients.
Results. Even after placing the artery clamp and cutting off the blood flow through the internal carotid artery no neurological deficits were observed with 18 patients, neither did we use temporary internal shunt with them. Five patients suffered problems with loss of consciousness, therefore we used the internal shunt. With all but one patient we performed a typical longitudinal endarterectomy and used the Dacron patch to close the carotid artery. Those patients underwent operation and post-operation treatment without complications and were dismissed from hospital five to seven days after the operation. Meanwhile, one patient’s condition worsened severely during preparation of the carotid artery even before the placement of the artery clamp, which resulted in paralysis on the contralateral side and loss of consciousness. The operation was suspended, the patient was treated conservatively.
Conclusions. The patients handled the procedure under block/ conduction anaesthesia well. Neurological testing of the patient awake during the procedure was a reliable method to ascertain cerebral blood circulation. Temporary internal shunt was used with patients who suffered a neurological deficit during the blockade of the carotid artery. As a result, the neurological deficit improved.
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References
North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991; 325: 445–53.
European Carotid Surgery Trialists’ Collaborative Group. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70–99%) or with mild (0–29%) carotid stenosis. Lancet 1991; 337: 1235–43.
North American Symptomatic Carotid Endarterectomy Trial (NASCET) investigators. Clinical alert: benefit of carotid endarterectomy for patients with high-grade stenosis of the internal carotid artery. Stroke 1991; 22: 816–7.
Cina CS, Clase CM, Haynes RB. Carotid endarterectomy for symptomatic carotid stenosis. Cochrane Database Syst Rev 2000: CD001081.
Ascher E, Markevich N, Hingorani AP, Kallakuri S, Gunduz Y. Internal carotid artery flow volume measurement and other intraoperative duplex scanning parameters as predictors of stroke after carotid endarterectomy. J Vasc Surg 2002; 35: 439–44.
Hobson RW 2nd, Lal BK, Chakhtoura EY et al. Carotid artery closure for endarterectomy does not influence results of angioplasty-stenting for restenosis. J Vasc Surg 2002; 35: 435–8.
Skelly CL, Meyerson SL, Curi MA et al. Routine early postoperative duplex scanning is unnecessary following uncomplicated carotid endarterectomy. Vasc Endovascular Surg 2002; 36: 115–22.
Gibbs BF. Temporary hypotension following endarterectomy for severe carotid stenosis: should we treat it? Vasc Endovascular Surg 2003; 37: 33–8.
Aackerstaff RG, Jansen C, Moll FL. Carotid endarterectomy and intraoperative emboli detection: Correlation of clinical, transcranial Doppler, and magnetic resonance findings. Echocardiography 1996; 13: 543–50.
De Borst GJ, Moll FL, van de Pavoordt HD, Mauser HW, Kelder JC, Ackerstaf RG. Stroke from carotid endarterectomy: when and how to reduce perioperative stroke rate? Eur J Vasc Endovasc Surg 2001; 21: 484–9.
Dunne VG, Besser M, Ma WJ. Transcranial Doppler in carotid endarterectomy. J Clin Neurosci 2001; 8: 140–5.
Hayes PD, Payne D, Lloyd AJ, Bell PR, Naylor AR. Patients’ thromboembolic potential between bilateral carotid endarterectomies remains stable over time. Eur J Vasc Endovasc Surg 2001; 22: 496–8.
Laman DM, Wieneke GH, van Duijn H, van Huffelen AC. High embolic rate early after carotid endarterectomy is associated with early cerebrovascular complications, especially in women. J Vasc Surg 2002; 36: 278–84.
Robless PA, Tegos TJ, Okonko D et al. Platelet activation during carotid endarterectomy and the antiplatelet effect of Dextran 40. Platelets 2002; 13: 231–9. 1
Stork JL, Kimura K, Levi CR, Chambers BR, Abbott AL, Donnan GA. Source of microembolic signals in patients with high-grade carotid stenosis. Stroke 2002; 33: 2014–8.
Stoll M, Hamann GF. Cerebrovascular reserve capacity. Nervenarzt 2002; 73: 711–8.
Munts AG, Mess WH, Bruggemans EF, Walda L, Ackerstaff RG. Feasibility and reliability of on-line automated microemboli detection after carotid endarterectomy. A transcranial Doppler study. Eur J Vasc Endovasc Surg 2003; 25: 262–6.
Lythgoe D, Simmons A, Pereira A, Cullinane M, Williams S, Markus HS. Magnetic resonance markers of ischaemia: their correlation with vasodilatory reserve in patients with carotid artery stenosis and occlusion. J Neurol Neurosurg Psychiatry 2001; 71: 58–62.
Nielsen MY, Sillesen HH, Jorgensen LG, Schroeder TV. The haemodynamic effect of carotid endarterectomy. Eur J Vasc Endovasc Surg 2002; 24: 53–8.
Hanel RA, Xavier AR, Kirmani JF, Yahia AM, Qureshi AI. Management of carotid artery stenosis: comparing endarterectomy and stenting. Curr Cardiol Rep 2003; 5: 153–9.
Soinne L, Helenius J, Tatlisumak T et al. Cerebral hemodynamics in asymptomatic and symptomatic patients with high-grade carotid stenosis undergoing carotid endarterectomy. Stroke 2003; 34: 1655–61.
Belardi P, Lucertini G, Ermirio D. Stump pressure and transcranial Doppler for predicting shunting in carotid endarterectomy. Eur J Vasc Endovasc Surg 2003; 25: 164–7.
Ouriel K, Greenberg RK, Sarac TP. Hemodynamic conditions at the carotid bifurcation during protective common carotid occlusion. J Vasc Surg 2001; 34: 577–80.
Zachrisson H, Berthelsen B, Blomstrand C, Holm J, Volkmann R. Influence of poststenotic collateral pressure on blood flow velocities within highgrade carotid artery stenosis: differences between morphologic and functional measurements. J Vasc Surg 2001; 34: 263–8.
Wellman B, Loftus C, Kresowik T, Todd M, Granner M. The differences in electroencephalographic changes in patients undergoing carotid endarterectomies while under local versus general anesthesia. Neurosurgery 1998; 43: 769–73.
D’Angelo V, Catapano G, Bozzini V et al. Propofol EEG burst suppression in carotid endarterectomy. J Neurosurg Sci 2001; 45: 157–62.
Laman DM, van der Reijden CS, Wieneke GH, van Duijn H, van Huffelen AC. EEG evidence for shunt requirement during carotid endarterectomy: optimal EEG derivations with respect to frequency bands and anesthetic regimen. J Clin Neurophysiol 2001; 18: 353–63.
Bond R, Rerkasem K, Counsell C et al. Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting). Cochrane Database Syst Rev 2002: CD000190.
Ballotta E, Da Gau G, Baracchini C, Manara R. Carotid eversion endarterectomy: Perioperative outcome and restenosis incidence. Ann Vasc Surg 2002; 16: 422–9.
McCleary AJ, Maritati G, Gough MJ. Carotid endarterectomy; local or general anaesthesia? Eur J Vasc Endovasc Surg 2001; 22: 1–12.
Spencer MP. Doppler microembolic signals for diagnosis of ulcerated carotid artery plaques. Echocardiography 1996; 13: 551–4.
Tangkanakul C, Counsell C, Warlow C. Local versus general anaesthesia for carotid endarterectomy. Cochrane Database Syst Rev 2000: CD000126.
Ayerdi J, Gupta SK, Sampson LN, Deshmukh N. Recognition of a non-recurrent laryngeal nerve during carotid endarterectomy. Cardiovasc Surg 2002; 10: 206–11.
Aldoori MI, Baird RN. Local neurological complication during carotid endarterectomy. J Cardiovasc Surg (Torino) 1988; 29: 432–6.
Sternbach Y, Illig KA, Zhang R et al. Hemodynamic benefits of regional anesthesia for carotid endarterectomy. J Vasc Surg 2002; 35: 333–9.
Krenn H, Deusch E, Jellinek H, Oczenski W, Fitzgerald RD. Remifentanil or propofol for sedation during carotid endarterectomy under cervical plexus block. Br J Anaesth 2002; 89: 637–40.
Perkins JMT, Galland RB. Indication for carotid endarterectomy: lessons learned from randomised trials. Earnshaw JJ, Murie JA eds. The evidence for vascular surgery. Gloucestershire: tfm Publishing, 1999: 1–6.
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