[Postoperative blood pressure alterations after carotid endarterectomy : Implications of different reconstruction methods]

Intraoperative intracarotid injection of anesthetics for postoperative blood pressure lability management in carotid endarterectomy: A meta-analysis of randomized controlled trials

Carotid endarterectomy (CEA) is commonly performed to prevent ischemic stroke in patients with significant carotid stenosis but is linked to perioperative blood pressure instability. Intracarotid lidocaine injection has been proposed to improve postoperative hemodynamic stability, but evidence of its efficacy and safety remains mixed. We conducted a meta-analysis of randomized controlled trials (RCTs) assessing the intraoperative intracarotid injection of local anesthetics in CEA, following PRISMA guidelines. Primary outcomes included postoperative blood pressure variability, adverse cardiovascular events, and overall complication rates. Secondary outcomes assessed mortality and incidence of restenosis in the short and long term. Seven RCTs comprising 652 patients were included, with lidocaine as the most commonly used anesthetic. No statistically significant differences were found in postoperative hypotension (OR 1.31, 95% CI 0.62-2.76), hypertension (OR 1.03, 95% CI 0.5-2.15), or mean blood pressure (MD 4.12 mmHg, 95% CI -3.35-11.60). Additionally, postoperative rates of arrhythmias (OR 1.22, 95% CI 0.7-2.12), myocardial infarction (OR 2.03, 95% CI 0.08-54.6), overall complications (OR 1.41, 95% CI 0.74-2.66), and cerebrovascular accidents (OR 2.55, 95% CI 0.61-10.57) did not differ significantly between groups. Intraoperative intracarotid injection of local anesthetic shows no significant benefit for stabilizing postoperative blood pressure in CEA patients. This meta-analysis did not support the hypothesized reduction in carotid sinus sensitivity. However, the small sample size increases the risk of type II error, and long-term outcomes, especially restenosis rates, require further investigation.

Perioperative blood pressure and heart rate alterations after carotid body tumor excision: a retrospective study of 108 cases

BACKGROUND

Arising from chemoreceptor cells, carotid body tumors (CBTs) are rare neoplasms associated with hemodynamics. Perioperative changes in blood pressure (BP) and heart rate (HR) are not completely understood.

METHODS

This retrospective, observational, controlled study included all CBT patients from 2013 to 2018 in Peking Union Medical College Hospital. Perioperative changes in BP/HR within or between unilateral/bilateral/control groups were investigated. Perioperative details across Shamblin types were also assessed.

RESULTS

This study included 108 patients (116 excised CBTs). The postoperative systolic BP and HR increased in both unilateral (mean difference of systolic BP = 5.9mmHg, 95% CI 3.1 ~ 8.6; mean difference of HR = 3.7 bpm, 95% CI 2.6 ~ 4.9) and bilateral (mean difference of systolic BP = 10.3mmHg, 95% CI 0.6 ~ 19.9; mean difference of HR = 8.4 bpm, 95% CI 0.5 ~ 16.2) CBT patients compared with the preoperative measures. Compared with control group, the postoperative systolic BP increased (difference in the alteration = 6.3mmHg, 95% CI 3.5 ~ 9.0) in unilateral CBT patients; both systolic BP (difference in the alteration = 9.2mmHg, 95% CI 1.1 ~ 17.3) and HR (difference in the alteration = 5.3 bpm, 95% CI 1.0 ~ 9.6) increased in bilateral CBT patients. More CBT patients required extra antihypertensive therapy after surgery than controls (OR = 2.5, 95% CI 1.14 ~ 5.5). Maximum tumor diameter, intraoperative vascular injury, continuous vasoactive agent requirement, total fluid volume, transfusion, estimated blood loss, operation duration, postoperative pathology, overall complications, and intensive care unit/hospital lengths of stay significantly varied among Shamblin types.

CONCLUSION

CBT excision may be associated with subtle perioperative hemodynamic changes. Perioperative management of CBT patients necessitates careful assessment, full preparation and close postoperative monitoring.

Influence of Eversion Endarterectomy and Patch Reconstruction on Postoperative Blood Pressure After Carotid Surgery

BACKGROUND

Post carotid blood pressure fluctuation and hypertension (PEH) are associated with increased risk for adverse outcome; there is limited evidence on the impact of eversion endarterectomy (E-CEA) versus conventional endarterectomy with patch closure (C-CEA) on postoperative blood pressure course.

PATIENTS AND METHODS

In this retrospective observational study, 859 consecutive carotid endarterectomy procedures between 2004 and 2014 (C-CEA n = 585 vs. E-CEA n = 274), were evaluated. Pre- and postoperative blood pressure values were recorded from recovery room until third postoperative day and compared between both techniques; influences on the dichotomous target variable "at least one postoperative blood pressure peak", that is need for postoperative vasodilators, were analyzed by a logistic regression model. Influences on postoperative systolic blood pressure were evaluated by a linear mixed effects regression model.

RESULTS

Preoperative baseline blood pressure was not different between both comparison groups. During postoperative course, significantly increased mean systolic blood pressure values in the E-CEA group from recovery room to second postoperative day (recovery room C-CEA: 129.2 mm Hg vs. E-CEA: 136.5 mm Hg; P < 0.001; first postoperative day C-CEA: 132.4 mm Hg vs. E-CEA: 139.3 mm Hg; P = 0.0002; second postoperative day C-CEA: 138.6 mm Hg vs. E-CEA: 143.1 mm Hg; P = 0.023) were observed. No hyperperfusion syndrome was detected as wells as no difference in postoperative complication rate. Frequency of antihypertensive interventions was also elevated in E-CEA group (C-CEA 22.1 % vs. E-CEA 31.8 %; P = 0.003). E-CEA (OR 1.591, 95% CI [1.146; 2.202]; P = 0.005) and presence of preoperatively elevated systolic readings (OR 1.015, 95%CI [1.006;1.024]; P < 0.001) was also associated with increased need for antihypertensive interventions.

CONCLUSION

E-CEA was associated with significantly elevated postoperative blood pressure, compared to C-CEA. C-CEA was associated with postoperative blood pressure decrease; however, no difference as to neurologic and surgical complications was detected between both surgical techniques in clinical practice.