Carotid sinus nerve blockade during carotid surgery: a randomised controlled trial

Carotid Endarterectomy with Autoarterial Remodeling of Bifurcation of the Common Carotid Artery and Carotid Endarterectomy with Patch Closure: Comparison of Methods

BACKGROUND

The objectives of our research were to identify whether the new method of carotid endarterectomy (CEA) with autoarterial remodeling of bifurcation of the common carotid artery (ARBCCA) influences daily parameters of blood pressure and heart rate (HR) while monitoring them on a daily basis and to assess the efficacy of the suggested method.

MATERIALS AND METHODS

It is a prospective randomized comparative study. The first group (n = 100) included patients that underwent ARBCCA, the second group (n = 100) included patients that underwent "classic" CEA with xenopericardial patch closure. Diurnal Holter recording of blood pressure and (HR) was performed before and after the surgical treatment in both groups.

RESULTS

Surgical treatment in both groups leads to an increase of HR, arterial hypertension time index by systolic blood pressure, and arterial hypertension time index by diastolic arterial blood pressure. The damage of carotid artery bulb increases sympathetic innervation and causes dysregulation of the baroreceptor mechanism.

CONCLUSIONS

In our study, we did not reveal a significant difference in the incidence of postoperative hypertension and the dependence of HR on the choice of surgical technique. Thus, the proposed ARBCCA method does not lead to an increased risk of pre-existing arterial hypertension development. A significant difference is found out on the parameter of the clamping time of carotid arteries in favor to ARBCCA group. Another advantage of the suggested technique is the number of restenosis greater than 50% during the 2-year follow-up (4 [4%] cases (ARBCCA group) versus 12 [12%] cases ["classic" CEA], respectively, P = .037).

Prolonged Autonomic Fluctuation Derived from Parasympathetic Hypertonia after Carotid Endarterectomy but not Stenting

BACKGROUND

Carotid endarterectomy (CEA) is a standard treatment for carotid artery stenosis, but the incidence after periprocedural myocardial infarction (MI) is not negligible. The mechanism for the higher risk of MI following CEA compared with the carotid artery stenting (CAS) is unclear. We hypothesized that it may be explained by different autonomic nervous responses.

METHODS

This prospective, nonrandomized, observational study enrolled 50 patients from 2 centers: 25 underwent CEA and 25 CAS. Cardiac autonomic nervous activity was evaluated using 24-hour high-resolution ambulatory electrocardiography with parameters such as deceleration capacity (DC) and heart rate variability before the procedure, and at 1 week and 1-3 months after the procedure.

RESULTS

One week after CEA, decreased DC and increased acceleration capacity were recognized. Standard deviation of sequential 5-minute NN interval means and the low-frequency and high-frequency components were all decreased. By the later phase measurement, these changes returned to baseline or beyond. The results suggest that diminished autonomic activity reversed to excessive parasympathetic dominance. In contrast, the patients treated by CAS showed no remarkable autonomic modification in the early or later phases.

CONCLUSIONS

Distinct changes of sympathovagal response observed after CEA coincides with the time at which MI onset occurs, suggesting prolonged autonomic fluctuation may be a factor in the MI incidence after CEA.

Percutaneous injection of lidocaine within the carotid body area in carotid artery stenting: an "old-new" technique

Severe bradycardia is a common untoward effect during balloon angioplasty when performing carotid artery stenting. Therefore atropine injection even before dilatation and the presence of an anesthesiologist are advocated in all patients. In the surgical literature, injection of a local anesthetic agent into the carotid sinus before carotid endarterectomy was performed in an attempt to ameliorate perioperative hemodynamic instability. This study was undertaken to test the hypothesis that percutaneous infiltration of the carotid sinus with local anesthetic immediately before balloon dilatation reduces bradycardia and ameliorates the need for atropine injection or the presence of an anesthesiologist. Infiltration of the carotid sinus with 5 ml of 1% lidocaine, 3 min before dilatation, was performed in 30 consecutive patients. No one exhibited any significant rhythm change that required atropine injection. The anesthesiologist did not face any hemodynamic instability during the carotid artery stenting procedure.

Carotid Sinus Nerve Blockade to Reduce Blood Pressure Instability Following Carotid Endarterectomy: A Systematic Review and Meta-analysis

OBJECTIVES

Local anaesthetic infiltration into the carotid sinus during carotid endarterectomy (CEA) has been recommended to minimise blood pressure fluctuations but its use remains controversial. The aim of this meta-analysis was to determine whether intra-operative administration of local anaesthetic reduces the incidence of haemodynamic instability following CEA.

MATERIALS AND METHODS

A search of the Medline, Pubmed and Embase databases and the Current Controlled Trials register identified four trials, which met the pre-defined inclusion criteria for data extraction. Pooled odds ratios with 95 per cent confidence intervals (c.i.) for the development of post-operative hypotension and hypertension were calculated using a random-effects model.

RESULTS

Outcomes of 432 patients were studied. Local anaesthetic blockade of the carotid sinus was associated with a pooled odds ratio of 1.25 (95 per cent c.i. 0.496 to 3.15); p=0.216) and 1.28 (95 per cent c.i. 0.699 to 2.33; p=0.428) for the development of post-operative hypotension and hypertension respectively. Although none reach significance there was a trend towards increased risk of developing a complication in those patients who received local anaesthetic.

CONCLUSIONS

There are insufficient data to determine the role of intra-operative local anaesthetic administration in reducing post-operative blood pressure lability following CEA. Conversely, the possibility of harm cannot be excluded on the basis of the currently available data.

Effect of lignocaine injection in carotid sinus on baroreceptor sensitivity during carotid endarterectomy

OBJECTIVES

This study was undertaken to test the hypothesis that there is a neural basis for baroreceptor deterioration during carotid endarterectomy (CEA), by investigating intraoperative hemodynamic changes induced by intraluminal carotid stretch stimulation, before and after application of local anesthetic to the adventitial layer of the carotid sinus region.

METHODS

This was a prospective study of 20 patients undergoing elective CEA. During CEA, before removal of the atheroma, intraluminal stretch simulation of the carotid baroreceptors (rub test) was performed before and after injection of 1% lignocaine into adventitial tissue of the artery in the region of the carotid sinus. Continuous measurements of mean arterial blood pressure (MAP), electrocardiographic r-r intervals (R-R), heart rate, cardiac vagal tone, and carotid sinus baroreflex were recorded to determine alterations in baroreceptor function.

RESULTS

Rub test before injection of lignocaine was associated with a decrease in MAP and heart rate and an increase in R-R, cardiac vagal tone, and carotid baroreflex response, indicating a functioning baroreflex. After lignocaine injection and repetition of the rub test, no significant change was seen in MAP, heart rate, R-R, cardiac vagal tone, or carotid baroreflex response, indicating a nonfunctioning baroreflex. Comparing the peak responses to the rub test stimulus before and after lignocaine injection showed significant differences for all variables (P <.05), with carotid baroreflex response and heart rate being highly significant (P <.0005).

CONCLUSIONS

The baroreflex response to intraluminal stretch stimulation of the carotid sinus area is operational in patients undergoing CEA, and this response is abolished by infiltration of local anesthetic into the periadventitial tissue around the carotid sinus.

Preoperative assessment and management to prevent complications during high-risk vascular surgery

OBJECTIVE

Most patients requiring vascular surgical reconstruction are at high risk for major morbidity and mortality, with certain vascular procedures at particularly high risk for complications. Although numerous comorbid conditions are precisely the risk factors that determine outcome, we review particular factors for each surgery that may be optimized to alter outcome and minimize postoperative complications.

DESIGN

Literature review.

RESULTS

Certain aspects of care are common to all vascular surgery procedures, including thoracoabdominal aortic aneurysm repair, pararenal and ruptured abdominal aortic aneurysm repair, mesenteric and renal revascularization, and carotid endarterectomy. Some factors that are important include careful preoperative assessment and optimization of cardiac, pulmonary, and renal function and volume status. In addition, the use of experienced teams during and after the procedure, as well as clear and continuous communication between all surgical team members, may improve outcome. Particular attention to procedural details is also crucial to achieving excellent results.

CONCLUSIONS

Patients needing vascular surgery often possess management challenges that increase the risk of perioperative complications. Meticulous attention to details during all phases of care, including preoperative optimization as well as intraoperative procedural conduct and communication, helps achieve optimal results and thus minimize the risk of complications.

Comparation of influence general and regional anesthesia on basic haemodynamic parameters during carotid endarterectomy

Carotid endarterectomy (CEA) is a preventive operation to reduce the incidence of embolic and thrombotic cerebral stroke. CEA carries a significant perioeperartive mortality rate from stroke and myocardial infarction, which may even approach 5%. Thus, anesthetic and surgical techniques are constantly under scrutiny to try to reduce this relatively high incidence of morbidity and mortality. Anesthetic technique for CEA is divided to general (GA) and regional (RA) anesthesia, performed by cervical plexus block. The aim this study was to examine changes of basic haemodynamic parameters, which routinely fallows during CEA in condition of GA and RA. After obtaining institutional approval and informed consent, we randomized 50 patients scheduled for CEA (Tab.1) in two groups (GA and RA). We fallow blood pressure: systolic (BPs), mean (BPm), diastolic (BPd), heart rate (HR), and RPP index at the examined patients. The examination performed in six control times: before induction of anesthesia (T1), 10 minutes after beginning of operation (T2), 5 minutes after cross clamping of arteria carotis (T3), 5 minutes after declamping arteria carotis (T4), 10 minutes (T5) and 2 hours after operation (T6). The results of study shows significant changes of blood pressure (BPs and BPm) and RPP index in T2 time in patinets undergoing GA. The changes occurred under influence of induction agent thio- pental. These changes were in homeostatic range. In RA patinets, no haemodynamic changes registrated in control times. Therefore, from haemodynamic aspect RA was superior to GA.