The influence of anesthetic technique on perioperative complications after carotid endarterectomy,☆☆,

Presented at the Seventeenth Annual Meeting of the Midwestern Vascular Surgical Society, Chicago, Ill., Sept. 10-11, 1993.
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Abstract

Purpose: This study evaluated the influence of anesthetic techniques on perioperative complications after carotid endarterectomy.

Methods: Perioperative complications, the use of a carotid artery shunt, the duration of the operative procedure and postoperative hospital course were retrospectively compared in 584 consecutive patients undergoing 679 carotid endarterectomies with use of either general anesthesia (n = 361) or cervical block regional anesthesia (n = 318). There was no significant difference in the preoperative medical characteristics between the two anesthetic groups. Symptomatic carotid artery disease was the indication for surgery in 247 (68.4%) patients receiving general anesthetics, whereas 180 (56.6%) patients treated with a cervical block anesthetic had a symptomatic carotid artery stenosis (p = 0.02).

Results: The perioperative stroke rate and stroke-death rate for the entire series was 2.4% and 3.2%, respectively, and was not significantly different between the anesthetic groups or between patients with symptomatic or asymptomatic disease. A carotid artery shunt was used in 61 (19.2%) patients receiving a cervical block anesthetic and 152 (42.1%) patients treated with a general anesthetic (p < 0.0001). Use of cervical block anesthesia was associated with a significantly shorter operative time, fewer perioperative cardiopulmonary complications, and a shorter postoperative hospitalization when compared with general anesthesia. Multivariate risk factor analysis indicated that age greater than 75 years, operative time greater than 3 hours, and the use of a carotid artery shunt were all independent risk factors for perioperative cardiopulmonary complications. When a carotid artery shunt was not analyzed as a multivariate risk factor, then general anesthesia became a significant risk factor for perioperative cardiopulmonary complications (risk ratio 2.08; p = 0.04).

Conclusions: We conclude that cervical block anesthesia is safer and results in a more efficient use of hospital resources than general anesthesia in the treatment of patients undergoing carotid endarterectomy. (J VASC SURG 1994;19:834-43.)

Section snippets

PATIENTS AND METHODS

The vascular registry at Washington University School of Medicine retrospectively reviewed the records of 584 consecutive patients undergoing 679 carotid endarterectomies during the last 6 years (April 1987 to March 1993) on the vascular surgery service at Barnes Hospital in St. Louis, Mo. Patients treated with combined carotid and coronary artery revascularization were excluded. Postoperative follow-up information was obtained through office visit records, letters to referral physicians, and

DEFINITIONS AND STATISTICAL ANALYSIS

The two anesthetic techniques were compared to identify differences in operative time, hospital stay, and perioperative complications and deaths with use of all the procedures (n = 679) performed in each anesthetic group. Perioperative morbidity was divided into neurologic and nonneurologic complications that occurred within 30 days of surgery. Neurologic complications were subdivided into temporary (transient ischemic attack, amaurosis fujax, seizure) or permanent (stroke, retinal infarction)

Perioperative morbidity and mortality

Perioperative neurologic events occurred after 35 (5.15%) operations (Table II). Nineteen (2.8%) were temporary neurologic deficits or perioperative seizures, and 16 were strokes for a perioperative stroke rate of 2.4%. Ten (2.8%) of the operations performed with the patient receiving general anesthetic were complicated by stroke, whereas six (1.9%) carotid endarterectomies performed with the patients receiving cervical block anesthetic were associated with stroke (p = 0.79). Operations for

DISCUSSION

The success and safety of carotid endarterectomy is impressive, with several multicenter prospective and retrospective studies reporting operative stroke-death rates of 3% to 6%. 1, 2, 9 The technical aspects of carotid endarterectomy are well established, and it appears unlikely that additional modifications in the existing surgical technique will lead to substantial improvements in operative morbidity and mortality rates. This report shifts the emphasis from surgical to anesthetic technique

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From the Section of Vascular Surgery, Department of Surgery, and Department of Anesthesia (Dr. Young-Beyer), Washington University School of Medicine, St. Louis.

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Reprint requests: Brent T. Allen, MD, One Barnes Plaza, Suite 5103 QT, St. Louis, MO 63110.

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