Outcome of carotid endarterectomy under local anaesthesia with respect to the patients' risk profile

Selective shunt during carotid endarterectomy using routine awake test with respect to a lower shunt rate

PURPOSE

To evaluate shunt rate and discuss the resultsrelated to selective shunt placement during carotid endarterectomy (CEA) using routine awake test.

METHODS

Patients with CEA from 2007 to 2011 were retrospectively reviewed from prospectively collected data. The need for shunt placement was determined by the awake test, based on the alteration in the neurologic examination. We collected data by using the clinical records and imaging studies, and investigated factors related to selective shunt such as collateral circulation and contralateral internal carotid artery (ICA) stenosis.

RESULTS

There were 45 CEAs under regional anesthesia with the awake test in 44 patients. The mean age was 61.8 ± 7.1 years old. There were 82.2% (37/45) of males, and 68.9% (31/45) of symptomatic patients. Selective shunt placement had been performed in only two (4.4%) patients. Among them fewer cases (4%) had severe (stenosis >70%) contralateral ICA lesions, and more cases (91%) of complete morphology of the anterior or posterior circulation in the circle of Willis. There was no perioperative stroke, myocardial infarctionor death, and asymptomatic new brain lesions were detected in 4 patients (9%), including 2 cases of selective shunt placement.

CONCLUSION

CEA under routine awake test could besafe and feasible method with low shunt placement rate in selected patients.

Interaction of cerebrovascular disease and contralateral carotid occlusion in prediction of shunt insertion during carotid endarterectomy

INTRODUCTION

To assess the possible role and the interaction of cerebrovascular disease and vascular stenosis on the necessity of shunt insertion during carotid endarterectomy (CEA).

MATERIAL AND METHODS

Eighty consecutive patients undergoing CEA under regional anaesthesia were prospectively enrolled. Patients were divided into two groups depending on whether they were shunted or not. The measured end-points were co-morbidities degree of contralateral and carotid stenosis and other intra- and postoperative outstanding parameters. ANOVA, Student's t and χ(2) tests were used (p<0.05). Variables differing significantly between groups and potential confounders were used in backward stepwise logistic regression to estimate the relative risk (RR, 95% CI) of shunt. In addition Wald's test (p<0.05) with and without adjustments for potential confounders was used with various different multivariate analysis models.

RESULTS

Contralateral stenosis and cerebral vascular accidents (CVA) were more frequently observed in shunted patients. The RR for patients with contralateral stenosis ≥ 50% was 1.3 (95% CI 1.0-1.5) and for patients with previous CVA was 1.2 (95% CI 1.0-1.4). For contralateral stenosis and CVA together the RR increased to 7.7 (95% CI 1.0-14.4). A model based on contralateral stenosis and CVA was found to be statistically significant (p=0.003) for shunt (RR=1.1, 95% CI 1.0-2.1). Relative excess risk due to interaction of both factors was 6.2.

CONCLUSIONS

The findings suggest that patients with contralateral stenosis ≥ 50% and previous CVA have a higher risk of requiring shunt use during CEA than patients with these risk factors separately.

Local Versus General Anesthesia for Carotid Endarterectomy

Like the earlier multicenter General Anesthesia (GA) versus Local Anaesthesia (LA) for carotid surgery (GALA) trial, a recent independent study showed no difference in transient ischemic attack, stroke, myocardial infarction, and death rates between carotid endarterectomy (CEA) performed under LA compared with GA. Besides these outcomes, however, several additional issues may be of interest when comparing the 2 modalities. Examples include the occurrence of post-CEA patient delirium, cognitive dysfunction, and health-related quality of life, as well as the cost-effectiveness, length of hospitalization, and resource utilization. This commentary discusses and compares these outcomes of CEA performed under LA versus GA.