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Review of 'Carotid Endarterectomy with Local Anesthesia and LMA/General Anesthesia'

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4
There is not yet consensus concerning superiority between the two methods.
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    Rated 4 of 5.
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Carotid Endarterectomy with Local Anesthesia and LMA/General Anesthesia

 Hani Annabi,  Charles Fleischer,  Robert Taylor (corresponding) (2014)
There is no clear consensus as to the appropriate anesthetic technique for patients undergoing a carotid endarterectomy. Such patients may have comorbid conditions, such as coronary artery disease, hyperlipidemia, and others. The two main anesthetic approaches are general anesthesia, including an endotracheal tube, with neurological monitoring and regional anesthesia that allows for an awake patient to be assessed neurologically. The objective of our study was to evaluate a novel anesthetic technique that combined general anesthesia with a laryngeal mask airway (LMA) plus regional anesthesia in the form of bupivacaine injected into the surgical site. Anesthesia was maintained with desflurane 4%, so the patient emerged rapidly for neurological assessment at the conclusion of surgery. We report on a case of a 55-year-old patient who underwent a successful carotid endarterectomy using this hybrid technique of general anesthesia with LMA plus regional anesthesia. This technique was safe and effective and the patient experienced no complications other than a hematoma on the left neck that was likely the result of long-term use of aspirin and Plavix. While further study is warranted, this hybrid technique of general anesthesia with LMA plus regional anesthesia holds promise for carotid endarterectomy patients.
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    Review information

    10.14293/S2199-1006.1.SOR-MED.ATXB4F.v1.RNPJGC

    This work has been published open access under Creative Commons Attribution License CC BY 4.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Conditions, terms of use and publishing policy can be found at www.scienceopen.com.

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    Review text

    Both general anesthesia and local anesthesia can be used for carotid endarterectomy (CEA). Each one has its own advantage and disadvantages. But, there is not yet consensus concerning superiority between the two methods. Below, I give some pros and cons for each method.



    General anesthesia:



    Pros: The patient can be immobilized, ventilator control is relatively easy to maintain, and the brain can be protected in the case of ischemic assault. Cons: It is slow to regain consciousness which is necessary for the neurological evaluation.



    Regional anesthesia:



    Pro: It is easy to assess the awake patient perioperatively and keep equivalent or even superior hemodynamic stability. This operation can be performed in awake patients too (Mendonça CT, Fortunato JA Jr, Carvalho CA, Weingartner J, Filho OR, Rezende FF, Bertinato LP. Carotid endarterectomy in awake patients: safety, tolerability and results. Rev Bras Cir Cardiovasc. 2014 Oct-Dec;29(4):574-80. doi: 10.5935/1678-9741.20140053).



    Con: It is possible that patients are not cooperative. Now, because the success of the CEA depends on reducing stroke (and perioperative complications) risk, which is decided by not only the anesthetic approach, but also the experience of the team (surgeon and anesthesiologist), careful preoperative assessment, as well as the intraoperative anesthetic management goals, in most cases, anesthesiologists choose the proper anesthesia according to the patient’s condition. The author supplied an optional anesthesia approach (hybrid technique of general anesthesia with LMA plus regional anesthesia) for a particular kind of patient. It is not “novel” and it has been used for this kind of patient already (i.e. see Marietta DR, Lunn JK, Ruby EI, Hill GE. Cardiovascular stability during carotid endarterectomy: endotracheal intubation versus laryngeal mask airway. J Clin Anesth. 1998 Feb;10(1):54-7.)



    Because this discussion is based on a case report and there appears to be no logical and statistic problems worthy of addressing. However, as indicated above, the references are not up to date.



    There are some additional new references such as the following:



    Cherprenet AL, Rambourdin-Perraud M, Laforêt S, Faure M, Guesmi N, Baud C, Rosset E, Schoeffler P, Dualé C.Local anaesthetic infiltration at the end of carotid endarterectomy improves post-operative analgesia. Acta Anaesthesiol Scand. 2015 Jan;59(1):107-14. doi: 10.1111/aas.12431. Epub 2014 Oct 28.



    Ciccozzi A, Angeletti C, Guetti C, Pergolizzi J, Angeletti PM, Mariani R, Marinangeli F. Regional anaesthesia techniques for carotid surgery: the state of art. J Ultrasound. 2014 May 1;17(3):175-83. doi: 10.1007/s40477-014-0094-5. eCollection 2014 Sep.



    In the authors favor, the language is easy to understand, there are no figures, and the article is systematically and logically organized; albeit, the introduction could have been a bit more concise.

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