Patient Satisfaction for Carotid Endarterectomy Performed under Local Anaesthesia

Local Anesthesia and Enhanced Recovery after Transcarotid Artery Revascularization

BACKGROUND

Transcarotid artery revascularization (TCAR) is a minimally invasive surgical treatment for carotid artery stenosis. This study describes a 10-year institutional experience of TCAR and the concurrent development of enhanced recovery protocols.

METHODS

Standardized practices were implemented at a single institution for patients undergoing TCAR. This included protocolized preoperative imaging and medical optimization, intraoperative workflow, and postoperative care. Additionally, vascular anesthesiology protocols were established for managing local and general anesthesia. A retrospective review of patients undergoing TCAR was subsequently conducted. Data on patient demographics, procedural details, and outcomes were analyzed from a prospectively maintained institutional database.

RESULTS

Across 321 patients, the median hospital stay after TCAR was 1.0 days with low-postoperative complications, most notably a 1.9% perioperative stroke-death rate.

CONCLUSION

Multidisciplinary collaboration is necessary to develop sustainable and effective enhanced recovery protocols. Implementation of these care pathways can improve patient outcomes and efficiency of care.

A Four-Arm Randomized Clinical Trial of Topical Pain Control for Sentinel Node Radiotracer Injections in Patients with Breast Cancer

BACKGROUND

Radioactive tracer injections for breast cancer sentinel lymph node mapping can be painful. In this randomized trial, we compared four approaches to topical pain control for radiotracer injections.

METHODS

Breast cancer patients were randomized (9 April 2021-8 May 2022) to receive the institutional standard of ice prior to injection (n = 44), or one of three treatments: ice plus a vibrating distraction device (Buzzy®; n = 39), 4% lidocaine patch (n = 44), or 4% lidocaine patch plus ice plus Buzzy® (n = 40). Patients completed the Wong-Baker FACES® pain score (primary outcome) and a satisfaction with pain control received scale (secondary). Nuclear medicine technologists (n = 8) rated perceived pain control and ease of administration for each patient. At study conclusion, technologists rank-ordered treatments. Data were analyzed as intention-to-treat. Wilcoxon rank-sum tests were used to compare pain scores of control versus pooled treatment arms (primary) and then control to each treatment arm individually (secondary).

RESULTS

There were no differences in pain scores between the control and treatment groups, both pooled and individually. Eighty-five percent of patients were 'satisfied/very satisfied' with treatment received, with no differences between groups. No differences in providers' perceptions of pain were observed, although providers perceived treatments involving Buzzy© more difficult to administer (p < 0.001). Providers rated lidocaine patch as the easiest, with ice being second.

CONCLUSION

In this randomized trial, no differences in patient-reported pain or satisfaction with treatment was observed between ice and other topical treatments. Providers found treatments using Buzzy® more difficult to administer. Given patient satisfaction and ease of administration, ice is a reasonable standard.

Transcarotid artery revascularization can safely be performed with regional anesthesia and no intensive care unit stay

OBJECTIVE

Hospital resource use is under constant review, and the extent and intensity of postoperative care requirements for vascular surgical procedures is particularly relevant in the setting of the coronavirus disease 2019 pandemic and its impact on staffed intensive care unit (ICU) beds. We sought to evaluate the feasibility of regional anesthesia (RA) and low-intensity postoperative care for patients undergoing transcarotid artery revascularization (TCAR) at our institution.

METHODS

All patients undergoing TCAR at a single institution from 2018 to 2020 were reviewed. Perioperative management (anticoagulation and antiplatelet therapy, hemodynamic monitoring, neurovascular examination, nursing instructions) was standardized by use of an institutional protocol. Anesthetic modality was at the surgeon's preference. Patients were transferred to a postanesthesia care unit for 2 hours followed by the step-down unit, to a postanesthesia care unit for 4 hours followed by the floor, or alternatively transferred to the ICU. Intravenous (IV) blood pressure medications could be administered at all environments except the floor. Recovery location and length of stay were recorded.

RESULTS

A total of 83 patients underwent TCAR during the study period. The mean age 72 ± 9 years and 59% were male. Thirty-six percent were symptomatic. RA was used for 84% with none converted to general anesthesia (GA) intraoperatively. Postoperatively, 7 of the 83 patients (8%) included in this study were monitored in an ICU overnight (decided perioperatively), mostly for patients with prior neurological symptoms, but in 1 case for postoperative neurological event and in another owing to pulseless electrical activity arrest. Six patients required IV antihypertensives and eight required IV vasoactive support postoperatively. The mean length of ICU stay was 3.7 ± 5.1 days. The mean length of hospital stay for all patients was 2.4 ± 3.3 days. The length of stay for patients undergoing TCAR with GA was higher than those undergoing TCAR with RA (4.2 ± 4.9 days vs 1.4 ± 1.2 days, respectively; P = .066). The incidence of stroke, death, and myocardial infarction was 2.4%. There was one postoperative stroke considered to be a recrudescence of prior stroke, and one respiratory arrest fatality in a frail patient with neck hematoma both of whom were treated under GA.

CONCLUSIONS

Using perioperative care protocols, TCAR can safely be performed while avoiding both GA and an ICU stay in most patients.

Comparison of Methods for Monitoring Intra-operative Cerebral Perfusion in Patients Undergoing Carotid Endarterectomy with Selective Shunting: A Systematic Review and Network Meta-Analysis of Randomised Controlled Trials and Cohort Studies

OBJECTIVE

This study aimed to analyse the influence of different methods of monitoring cerebral perfusion (MCP) on stroke, death, and use of intraluminal shunt during carotid endarterectomy (CEA).

METHODS

A systematic review and network meta-analysis was conducted and registered in the PROSPERO registry (CRD42021246360). Medline, Embase, CENTRAL, and Web of Science were searched. Randomised controlled trials (RCTs) and cohort studies with > 50 participants that compared clinical outcomes for different MCP in patients undergoing CEA were included. Papers reporting one or a combination of two of the following MCPs were included in the analysis: awake testing (AT), near infrared spectroscopy (NIRS), electroencephalography (EEG), somatosensory evoked potential (SSEP), motor evoked potential (MEP), transcranial Doppler (TCD), and stump pressure (SP). A random effects network meta-analysis was performed using a binomial likelihood function with a specified logit link for peri-operative stroke or death and shunting as outcomes. Near infrared spectroscopy was excluded due to the lack of studies that could be used for statistical analysis.

RESULTS

Of 1 834 publications, 17 studies (15 cohort studies and two RCTs) including 21 538 participants were incorporated in the quantitative analysis. Electroencephalography was used in the largest number of participants (7 429 participants, six studies), while AT was used in the highest number of studies (10 studies). All monitoring modalities had worse outcomes with respect to stroke or death when compared with AT, with ORs ranging between 1.3 (95% credible interval [CrI] 0.2 - 10.9) for SSEP + MEP and 3.1 (CrI 0.3 - 35.0) for patients monitored with a combination of EEG and TCD. However, the wide CrI indicated that there is no statistically significant difference between the monitoring methods. Patients monitored with a combination of EEG and TCD had the lowest odds of being shunted, while SP had the highest odds of being shunted, also with no statistically significant difference.

CONCLUSION

There is a lack of high quality data on this topic in the literature. The present study showed no significant difference between monitoring methods investigated in the network meta-analysis.

Local versus general anaesthesia for carotid endarterectomy

BACKGROUND

Carotid endarterectomy may significantly reduce the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks that may be minimised by performing the operation under local rather than general anaesthetics. This is an update of a Cochrane Review first published in 1996, and previously updated in 2004, 2008, and 2013.

OBJECTIVES

To determine whether carotid endarterectomy under local anaesthetic: 1) reduces the risk of perioperative stroke and death compared with general anaesthetic; 2) reduces the complication rate (other than stroke) following carotid endarterectomy; and 3) is acceptable to individuals and surgeons.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and two trials registers (to February 2021). We also reviewed reference lists of articles identified.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing the use of local anaesthetics to general anaesthetics for people having carotid endarterectomy were eligible.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data, assessed risk of bias, and evaluated quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) tool. We calculated a pooled Peto odds ratio (OR) and corresponding 95% confidence interval (CI) for the following outcomes that occurred within 30 days of surgery: stroke, death, ipsilateral stroke, stroke or death, myocardial infarction, local haemorrhage, and arteries shunted.

MAIN RESULTS

We included 16 RCTs involving 4839 participants, of which 3526 were obtained from the single largest trial (GALA). The main findings from our meta-analysis showed that, within 30 days of operation, neither incidence of stroke nor death were significantly different between local and general anaesthesia. Of these, the incidence of stroke in the local and general anaesthesia groups was 3.2% and 3.5%, respectively (Peto odds ratio (OR) 0.91, 95% confidence interval (CI) 0.66 to 1.26; P = 0.58; 13 studies, 4663 participants; low-quality evidence). The rate of ipsilateral stroke under both types of anaesthesia was 3.1% (Peto OR 1.03, 95% CI 0.71 to 1.48; P = 0.89; 2 studies, 3733 participants; low-quality evidence). The incidence of stroke or death in the local anaesthesia group was 3.5%, while stroke or death incidence was 4.1% in the general anaesthesia group (Peto OR 0.85, 95% CI 0.62 to 1.16; P = 0.31; 11 studies, 4391 participants; low-quality evidence). A lower rate of death was observed in the local anaesthetic group but evidence was of low quality (Peto OR 0.61, 95% CI 0.35 to 1.06; P = 0.08; 12 studies, 4421 participants).

AUTHORS' CONCLUSIONS

The incidence of stroke and death were not convincingly different between local and general anaesthesia for people undergoing carotid endarterectomy. The current evidence supports the choice of either approach. Further high-quality studies are still needed as the evidence is of limited reliability.

High Patient Satisfaction With Local Anesthesia and Light Sedation in a Novel Fast-Track Setup for Sacrospinous Fixation

OBJECTIVES

Simple prolapse operations can be performed using local anesthesia. However, this has not been the case for advanced pelvic organ prolapse operations. The aim of this study was to investigate the patient-reported feasibility and acceptability of local anesthesia and light sedation for sacrospinous fixation (SSF).

METHODS

This is a prospective observational study on 105 women who underwent SSF in a public outpatient setting from April 2016 to October 2017. They received infiltration anesthesia with mepivacaine or lidocaine together with a pudendal nerve block with Marcaine. Local anesthesia was supplemented by intravenous light sedation and pain reliever. A Local Anesthetic Intraoperative Experience Questionnaire was used to evaluate patient experience.

RESULTS

One patient was converted to general anesthesia. Eighty-eight women answered the questionnaires. Ninety-nine percent defined themselves as satisfied or very satisfied with the anesthesia. Little or no pain during the operation was reported by 92% and 92% would choose the same type of anesthesia again. No adverse effect of the anesthetic procedure was observed. The median (range) admission time was 12 (4.5-48) hours, and 81% of the patients could be discharged on the day of surgery. At follow-up after 8 weeks and 6 months, no patients reported adverse events to the anesthesia.

CONCLUSIONS

The SSF can be performed using local anesthesia and light sedation with high degree of patient satisfaction. These preliminary data indicate that the concept of ambulatory surgery might be implemented more widely if the use of local anesthesia is also applied to more advanced surgical procedures.

Patient satisfaction and experience with anesthesia: A multicenter survey in Saudi population

BACKGROUND AND OBJECTIVES

Patients' satisfaction of anesthesia outcomes is a major part of the overall quality of health care. The aim of this study is to evaluate patient's satisfaction whether pre- or post-operative as well as overall impression using a multicenter prespecified survey tool.

METHODS

Three hundred and three patients who underwent surgery regardless the type of anesthesia were surveyed. The interview conducted face-to-face before surgery then within the first 24 h of surgery. We recorded all basic demographics of patients, the quality of postoperative symptoms control, and the impression about anesthesia team.

RESULTS

The overall satisfaction level was moderate (56.5%) with nearly half of the patients dissatisfied with their anesthetic care due to different reasons. Nausea and vomiting control was the most common postoperative reasons for dissatisfaction followed by pain control with 35.6% and 31.7%, respectively.

CONCLUSION

Type of anesthesia, giving an informative visit to the patient, and the control of postoperative symptoms are the most important predictors of patients' satisfaction.

Patients' Experiences During Carotid Endarterectomy Performed Under Local Anesthesia

PURPOSE

To describe patients' experiences undergoing a carotid endarterectomy (CEA) under local anesthesia.

DESIGN

Explorative qualitative design.

METHODS

Semistructured interviews with 15 participants who had undergone CEA under local anesthesia, analyzed by content analysis.

FINDINGS

Undergoing CEA under local anesthesia entails enduring stress with no possibility of withdrawal. Patients' lack of understanding of local anesthesia and experiencing pain and discomfort caused feelings of stress. The surgery resulted in a loss of control; patients had to surrender their autonomy to someone else. The nurse anesthetist was the link to the world outside the operating room (OR), and that nurse conveyed feelings of safety and security during the surgery.

CONCLUSIONS

Patients' experiences ranged from being pleased with the surgical procedure and local anesthesia to vowing never to undergo such a procedure again. It is important to focus on the patients' experiences and feelings when choosing a method of anesthesia.

Out-patient flexible carbon dioxide laser surgery for benign laryngopharyngeal pathologies via transnasal flexible laryngo-oesophagoscopy

OBJECTIVE

To assess the feasibility and outcomes of flexible carbon dioxide laser surgery in a clinic-based setting.

METHODS

A prospective study was conducted in a tertiary centre. Clinical indications, clinical outcomes and patient satisfaction were assessed in patients treated with flexible carbon dioxide laser surgery via transnasal endoscopy and followed up over a period of up to nine months. Patients who were not fit for general anaesthesia or those with lesions that cannot be accessed by micro-laryngoscopy were included.

RESULTS

A total of 13 patients (14 procedures) were included. Clinical indications for surgery were small-to-medium sized benign pathologies in the upper aero-digestive tract. Patient satisfaction was assessed using a validated questionnaire.

CONCLUSION

Early data suggest that flexible carbon dioxide laser is a versatile and feasible instrument with potential applications for a range of benign pathologies in the upper aero-digestive tract.

What Should We Do with Asymptomatic Carotid Stenosis?

The benefit of prophylactic carotid endarterectomy (CEA) for patients with asymptomatic severe carotid stenosis in the major randomised surgical studies was small, expensive and may now be absorbed by improvements in best practice medical intervention. Strategies to identify patients with high stroke risk are needed. If surgical intervention is to be considered the complication rates of individual surgeons should be available. Clinicians will differ in their interpretation of the same published data. Maintaining professional relationships with clinicians from different disciplines often involves compromise. As such, the management of a patient will, in part, depend on what kind of specialist the patient is referred to. The clinician's discussion with patients about this complex issue must be flexible to accommodate differing patient expectations. Ideally, patients prepared to undergo surgical procedures should be monitored in a trial setting or as part of an audited review process to increase our understanding of current practice outcomes.

Are patients satisfied after peripheral nerve blockade? Results from an International Registry of Regional Anesthesia

INTRODUCTION

Peripheral nerve blockade (PNB) is associated with superior outcomes compared with opioids; however, little is known regarding patients' perceptions of the care they have received. Patient satisfaction is emerging as an important indicator of quality of health care, and identifying deficiencies in discrete aspects of satisfaction may allow targeted interventions to improve quality. In this study, we analyze data relevant to patient satisfaction from the International Registry of Regional Anesthesia. The primary objective of this analysis was to report the results of a patient-satisfaction questionnaire and to determine predictors associated with unwillingness to have PNB repeated in the case of future surgery.

METHODS

The questionnaire used in this study was derived from this registry's results and from previously validated questionnaires and addressed 3 domains of importance, namely, provision of information, pain, and interaction with the anesthesiologist. The 11-item written, multidimensional questionnaire was given to patients within 2 days postoperatively. The primary outcome was willingness to have PNB repeated in the event of future similar surgery.

RESULTS

Data related to 9969 surgical procedures were collected between July 1, 2011, and March 31, 2013. The survey response rate was 61.6%. Most respondents-94.6% (95% confidence interval, 94.0%-95.1%)--stated that they were willing to have a repeat PNB. Ninety percent of respondents were satisfied or completely satisfied with the information provided about the nerve block, as well as the anesthesiologist-patient interaction. Patients who were dissatisfied with either of these domains (ie, information provision or professional interaction) were less willing to undergo repeat PNB, as were patients who reported significant pain during the nerve block procedure.

CONCLUSIONS

A high proportion of survey respondents were willing to undergo repeat PNB in case of future surgery and were satisfied with their anesthetic care. Targeted interventions to improve quality of PNB should be aimed at improving comfort, information provision, and physician-patient interaction.

Regional anaesthesia techniques for carotid surgery: the state of art

PURPOSE

This review will analyse some aspects of regional anaesthesia (RA) for carotid endarterectomy (CEA), a surgical procedure which requires a strict monitoring of patient's status. RA remains an important tool for the anaesthesiologist. Some debates remain about type and definition of regional anaesthesia, efficacy and safety of the different cervical block techniques, the right dose, concentration and volume of local anaesthetic, the use of adjuvants, the new perspectives: ultrasonography, the future directions.

METHODS

A literature search was performed for journal articles in English language in the PubMed Embase and in The Cochrane Library database, from January 2000 to December 2013. The electronic search strategy contained the following medical subject headings and free text terms: local anaesthesia versus general anaesthesia for endarterectomy, superficial and deep cervical block, complications of cervical nerve block, ultrasound guidance of superficial and deep cervical plexus block.

CONCLUSIONS

The gold standard for RA will be achieved after overcoming a number of limitations by a more extensive use of ultrasonography, by combining general and regional anaesthesia, including conscious anaesthesia, by defining the appropriate volume, concentration and dosage of local agents and by addition of adjuvants.

Local versus general anaesthesia for carotid endarterectomy

BACKGROUND

Carotid endarterectomy may significantly reduce the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks that may be reduced by performing the operation under local rather than general anaesthetic. This is an update of a Cochrane Review first published in 1996, and previously updated in 2004 and 2008.

OBJECTIVES

To determine whether carotid endarterectomy under local anaesthetic: (1) reduces the risk of perioperative stroke and death compared with general anaesthetic; (2) reduces the complication rate (other than stroke) following carotid endarterectomy; and (3) is acceptable to patients and surgeons.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (September 2013), MEDLINE (1966 to September 2013), EMBASE (1980 to September 2013) and Index to Scientific and Technical Proceedings (ISTP) (1980 to September 2013). We also handsearched relevant journals, and searched the reference lists of articles identified.

SELECTION CRITERIA

Randomised trials comparing the use of local anaesthetic to general anaesthetic for carotid endarterectomy were considered for inclusion.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial quality and extracted data. We calculated a pooled Peto odds ratio (OR) and corresponding 95% confidence interval (CI) for the following outcomes that occurred within 30 days of surgery: stroke, death, stroke or death, myocardial infarction, local haemorrhage, cranial nerve injuries, and shunted arteries.

MAIN RESULTS

We included 14 randomised trials involving 4596 operations, of which 3526 were from the single largest trial (GALA). In general, reporting of methodology in the included studies was poor. All studies were unable to blind patients and surgical teams to randomised treatment allocation and for most studies the blinding of outcome assessors was unclear. There was no statistically significant difference in the incidence of stroke within 30 days of surgery between the local anaesthesia group and the general anaesthesia group. The incidence of strokes in the local anaesthesia group was 3.2% compared to 3.5% in the general anaesthesia group (Peto OR 0.92, 95% CI 0.67 to 1.28). There was no statistically significant difference in the proportion of patients who had a stroke or died within 30 days of surgery. In the local anaesthesia group 3.6% of patients had a stroke or died compared to 4.2% of patients in the general anaesthesia group (Peto OR 0.85, 95% CI 0.63 to 1.16). There was a non-significant trend towards lower operative mortality with local anaesthetic. In the local anaesthesia group 0.9% of patients died within 30 days of surgery compared to 1.5% of patients in the general anaesthesia group (Peto OR 0.62, 95% CI 0.36 to 1.07). However, neither the GALA trial or the pooled analysis were adequately powered to reliably detect an effect on mortality.

AUTHORS' CONCLUSIONS

The proportion of patients who had a stroke or died within 30 days of surgery did not differ significantly between the two types of anaesthetic techniques used during carotid endarterectomy. This systematic review provides evidence to suggest that patients and surgeons can choose either anaesthetic technique, depending on the clinical situation and their own preferences.

The patients' perspective of carotid endarterectomy

INTRODUCTION

No studies as yet have directly evaluated the patients' perspective of carotid endarterectomy (CEA). Here, we determine patient satisfaction, understanding, and perception of CEA.

METHODS

Consecutive patients were identified from a prospectively maintained carotid database. A validated 10-point telephone questionnaire was conducted. Questions related to preoperative symptoms, experience of procedure, future interventions, and overall patient satisfaction.

RESULTS

Of the 192 patients included, 136 completed the questionnaire (71% response rate). Ninety-two percent were satisfied with the explanation received, however, only 48% understood that CEA aimed to prevent future stroke. Eighty-five percent of patients received local anesthesia (LA) CEA, with 16% reporting severe or unbearable pain. Most patients (83%) would repeat CEA if necessary and 67% stated a future preference for LA CEA. The majority of patients (96%) were satisfied with their treatment overall.

CONCLUSIONS

Most patients were satisfied with CEA. Greater emphasis could be placed on improving preoperative information-giving and intraoperative analgesia.

Systematic Review of the Operative Risks of Carotid Endarterectomy for Recently Symptomatic Stenosis in Relation to the Timing of Surgery

Background and Purpose— Reliable data on the risk of carotid endarterectomy (CEA) in relation to timing of surgery are necessary to plan CEA most effectively, to adjust risks for case-mix, and to understand the mechanisms of operative stroke.

Methods— We performed a systematic review of all studies published from 1980 to 2008 inclusive that reported the risk of stroke and death due to CEA in relation to the time between presenting symptom and surgery. Pooled estimates of risk by the time since the last event were obtained by Mantel–Haenszel meta-analysis.

Results— Of 494 published operative series, only 47 stratified risk by timing of surgery. The pooled absolute risks of stroke and death after urgent CEA were high in patients with stroke-in-evolution (20.2%, 95% CI 12.0 to 28.4) and in patients with crescendo TIA (11.4%, 6.1 to 16.7), with no trends toward reduced risks in more recent studies. However, there was no significant difference between early and later CEA in neurologically stable patients with recent TIA or nondisabling stroke (<1 week versus ≥1 week, OR=1.2, 0.9 to 1.7, P =0.17; <2 weeks versus ≥2 weeks, OR=1.2, 0.9 to 1.6, P =0.13).

Conclusions— Emergency endarterectomy for stroke-in-evolution has a high operative risk, but the risk may be somewhat lower in patients with crescendo TIA. Surgery in the first week in neurologically stable patients with TIA or minor stroke is not associated with a substantially higher operative risk than delayed surgery. More data are required on the risk and benefit of more urgent surgery for TIA and minor stroke and for early versus delayed surgery in patients with major nondisabling stroke.

Patient anxiety and conscious surgery

The amount of surgery undertaken on the conscious patient is increasing. However, many patients are anxious and resistant to such surgery. Patients (n = 214) were surveyed to determine their related apprehensions. Being awake, feeling or seeing the body cut open and experiencing pain all increased anxiety. The potential for insufficient information provision was also a source of concern. Formal management of intraoperative apprehension may help limit anxiety and expel apparent misapprehensions.

Local versus general anaesthesia for carotid endarterectomy

BACKGROUND

Carotid endarterectomy reduces the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks which may be lessened by performing the operation under local rather than general anaesthetic. This is an update of a Cochrane review first published in 1996, and previously updated in 2004.

OBJECTIVES

To assess the risks of endarterectomy under local compared with general anaesthetic.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched December 2007), MEDLINE (1966 to April 2007) EMBASE (1980 to April 2007) and Index to Scientific and Technical Proceedings (ISTP, 1980 to April 2007). We also handsearched six relevant journals to April 2007, and searched the reference lists of articles identified. For the previous version of this review we handsearched a further seven journals to 2002 and in August 2001 advertised the review in Vascular News, a newspaper for European vascular specialists.

SELECTION CRITERIA

Randomised trials and non-randomised studies comparing carotid endarterectomy under local versus general anaesthetic.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial quality and extracted the data independently.

MAIN RESULTS

Nine randomised trials involving 812 operations, and 47 non-randomised studies involving 24,181 operations were included. Meta-analysis of the randomised studies showed that there was no evidence of a reduction in the odds of operative stroke, but the use of local anaesthetic was associated with a significant reduction in local haemorrhage (odds ratio 0.30, 95% confidence interval 0.12 to 0.77) within 30 days of the operation. However, the randomised trials were too small to allow reliable conclusions to be drawn, and in some studies intention-to-treat analyses were not possible because of exclusions. Meta-analsis of the non-randomised studies showed that the use of local anaesthetic was associated with significant reductions in the odds of stroke (38 studies), death (42 studies), stroke or death (27 studies), myocardial infarction (27 studies), and pulmonary complications (seven studies), within 30 days of the operation. The methodological quality of the non-randomised trials was questionable. Thirteen of the non-randomised studies were prospective and 36 reported on a consecutive series of patients. In eleven non-randomised studies the number of arteries, as opposed to the number of patients, was unclear.

AUTHORS' CONCLUSIONS

There is insufficient evidence from randomised trials comparing carotid endarterectomy performed under local and general anaesthetic. Non-randomised studies suggest potential benefits with the use of local anaesthetic, but these studies may be biased.

[Assessment of patient satisfaction after regional anaesthesia in two institutions]

OBJECTIVES

This study was designed to assess patient satisfaction after regional anaesthesia for limb surgery.

METHODS

An anaesthesia satisfaction questionnaire was developed, validated (Kappa coefficient) and submitted to 314 patients operated in two institutions (one university hospital with anaesthesiology residents and one specialised in orthopaedics with experienced anaesthesiologists). Items explored were information modalities, pain and anxiety during procedure and global satisfaction rated with four levels (very satisfied [VS], satisfied [S], partially satisfied [PS], non-satisfied [NS]). Patients were interviewed by telephone at postoperative D1 and D8 by a pharmacist student not involved in the patient's care.

RESULTS

Inspite of a high level of patient satisfaction at D8 (VS: 50%, S: 44%), some interesting aspects should be emphasised: a) sedation given before nerve block was not efficient to reduce anxiety and pain during procedure; b) VS levels decreased from D1 (56%) to D8 (50%) mainly because of late postoperative pain (after discharge) and discomforts; c) willingness to undergo the same nerve block again (294/314) was not correlated with patient's satisfaction since among PS and NS patients, a majority (9/15) wished for a block in case of renewed limb surgery; d) multivariate analysis showed that VS level was highly correlated with the quality of communication by the anaesthesiologist mainly for informations about pre and postoperative periods. No correlation was found with pain level during procedure; e) satisfaction levels were not different in the two institutions.

CONCLUSION

This study has emphasised some important factors of patient satisfaction which were not sufficiently taken into account in our daily practice.

Review of developments in anesthesia for carotid endarterectomy

PURPOSE OF REVIEW

Analysis of recent data indicates a clear benefit of carotid endarterectomy for symptomatic patients with high-grade carotid artery stenosis, and a marginal benefit for asymptomatic patients. Despite myriad challenges presented by patients undergoing carotid endarterectomy, excellent outcomes have been achieved and many centers have shown the technique to be safe as an outpatient procedure for specific populations. Greater attention to comorbidities and their management in the perioperative period is increasingly important as older and more complex patients present for invasive treatment of carotid disease. Scientific study aimed at defining which characteristics merit our attention will only lead to improved outcomes and greater understanding of carotid disease, endarterectomy and anesthesia. While controversial, the efficacy, safety, and durability of stenting and angioplasty have improved in recent years. Potential advantages of stenting and angioplasty of the carotid artery include avoiding cranial nerve damage, wound hematoma, and general anesthesia. Staying abreast of the science regarding such endovascular therapies will be increasingly important.

RECENT FINDINGS

The major areas of investigative interest include patient selection, anesthetic technique, and monitoring for carotid endarterectomy, and durability of stenting and angioplasty of the carotid artery.

SUMMARY

Patients with significant comorbidities may be managed safely by a variety of anesthetic techniques. Maintaining hemodynamic stability and monitoring cerebral oxygen delivery remain important goals of perioperative management. Recent data regarding the durability and safety of stenting and angioplasty of the carotid artery suggest that outcomes may approach those of carotid endarterectomy.

A Modified Combined Approach to Operative Carotid and Coronary Artery Disease: 82 Cases in 8 Years

BACKGROUND

A significant number of patients undergoing coronary artery surgery have severe carotid artery disease. It is also true that up to half of the patients undergoing carotid endarterectomy (CEA) have severe treatable coronary lesions. This study aims to review data regarding 82 patients of combined approach in 8 years; the second half consists of 44 patients whose CEA was performed under local anesthesia. It compares results of the conventional and the modified approaches to simultaneous surgery.

METHODS

All 82 patients who planned to have a concomitant procedure were recorded prospectively between 1995 and 2003. From 1998, the surgical technique has been modified to switch to local anesthesia for CEA, rather than perform under a single general anesthetic period. All pre-and perioperative data as well as in-hospital and outpatient control (mid- to long-term) data were recorded. A P-value of less than .05 was considered as significant. Analysis of survival was performed by using the Kaplan-Meier method and the log-rank test.

RESULTS

The 30-day follow-up was 100% complete for all patients. All patients were followed for 59.59 to 114 months) months postoperatively. Three patients (6.8%) in the modified and 2 (5.2%) in the standard group had intraluminal shunting (P > .05). In the standard group, 3 patients expired and 3 had perioperative stroke; only 1 patient had a stroke in the modified group and two expired (P > .05). Mean survival time according to Kaplan-Meier test was 109.97, SE 2.84, 95% CI (104.41-115.52) months for the former group, whereas it was 62.79, SE 1.20, 95% CI (60.4565.13) months for the latter. Actuarial estimates of survival during ten-year follow up were 94.44% SE 3.83 in ten-year follow-ups and 97.67% SE 2.30 in 5-year follow-ups for the modified group (P > .05).

CONCLUSIONS

Avoidance from extended periods of general anesthesia and cardiopulmonary bypass periods as well as immediate recognition of impaired cerebral flow during CEA and the time it provides to take preventive measures are the most important benefits of the modified technique without significantly changing hospital and long-term mortality and stroke. It may also reduce the cost and the waiting period for the suffering patient.