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

The paper topic is clinically relevant by suggesting an alternative anesthetic protocol for a debated surgical procedure (CEA) bearing a high mortality rate. The paper is comprehensible with good organization and appropriate references, but it is missing some relevant clinical studies. The lack of perioperative clinical data such as intraoperative patient vital parameters or means of brain monitoring doesn’t allow an appraisal of the benefits of the procedure while, by missing patient body weight, the reported drug dosages appear quite loose.

The reported hybrid technique of general anesthesia with LMA offers a potential for minimizing intraoperative cardiac depression leading to unwanted hypotension during CEA, but it can’t guarantee for the mandatory perioperative hemodynamic stability claimed by the field literature. The choice of desflurane as brain protection from ischemia is supported at clinical effective concentrations, but such potential benefit can be questionable at 0,66 MAC, bearing also the risk of an abrupt anesthetic recovery and of crossclamping or postop hypertension.

The advantages brought about by the use of a LMA, reported for CEA by Holmstrom et Al. [Br. J. Anaesth. (2007) 99 (1):119-131], are limited to intubation, thus meeting the needs of a difficult airway (Mallampati grade 3 and 4) which doesn’t seem to be a feature of the reported case. A safer and definitive airway control could alternatively be achieved by a preventive awake ETT, by nasotracheal intubation or by a percutaneous tracheotomy.
As for regional analgesia, the quick and simple technique adopted by the paper authors leaves some doubts about the reported complex and risky procedure including superficial and deep cervical plexus blocks.

A hesitation about the validity of the paper ensues from the assertion that the proposed hybrid anesthetic procedure eliminates the need for an arterial line, which is instead deemed routine, allowing direct blood pressure and arterial blood gases monitoring. Such critical patients undergoing a CEA procedure should have extensive monitoring of brain function and perfusion, and if at risk of poor ventricular function or myocardial ischaemia more advanced cardiovascular monitoring should be considered.

Naples, April 12, 2015
Giancarlo Vesce VMD