Carotid Endarterectomy with Regional Anesthesia

DECREASED STROKE RISK CITED AS PRIMARY BENEFIT OF REGIONAL ANESTHESIA, ESPECIALLY IN OLDER PATIENTS

Carotid endarterectomy (CEA) has long been used in selected patients with carotid stenosis, especially in those with 70 to 99 percent stenosis of the internal carotid artery.1 The majority of those surgeries are performed under general anesthesia; however, an increasing number of neurosurgeons believe that performing the procedure under regional and local anesthesia results in superior outcomes. Assistant Professor of Neurosurgery, Scott Simon, M.D., strongly agrees. In fact, he and Robert Harbaugh, M.D., professor and chair of the Department of Neurosurgery, insist that all CEA patients receive regional anesthesia, in the absence of mitigating factors.

As Simon states, “Most of our patients have already had a stroke, and there’s evidence that putting a brain that’s already been injured under general anesthesia can cause cognitive limitations when the patient wakes up.” When asked about the landmark CREST (Carotid Revascularization Endarterectomy versus Stenting Trial), which appeared to indicate that stenting offers similar outcomes to surgery, Simon points out that the data clearly indicate a much lower risk of postoperative stroke with CEA (2.3 percent versus 4.1 percent with stenting),1 a significant indicator of patient quality of life post-procedure. Further, of more than 2,500 patients in the CREST trial, only 10 percent received regional anesthesia.1

Adds Simon, “I think that to say awake surgery is ‘controversial’ is going too far. However, up until now, the issue of performing CEA under regional or general anesthesia awake has fallen into the category of surgeon preference. I think that it’s going to become clear that the type of anesthesia does, in fact, make a difference. Moving forward, we believe that awake CEA is going to become the standard of care.”

Table 2 - Perioperative Data, Intensive Care Unit and Hospitalization Time, Mortality, MI, Stroke and TIA ratesThese observations are confirmed by Harbaugh’s extensive clinical research into the benefit of regional anesthesia for CEA. His multiple published series demonstrated a decrease in post-operative hospital stay and non-stroke related complications,2 the kind noted in the CREST trial. Furthermore, another study conducted a retrospective analysis of a total of 165 CEA procedures performed on 150 patients with general anesthesia and 200 CEA procedures performed on 179 patients with local anesthesia.3 The patients who received general anesthesia had a significantly higher permanent stroke rate compared to those who received regional anesthesia (n = 12 versus n = 2; P < .05).3

Concludes Simon, “It’s not necessarily finding the newest technique, but rather maximizing the potential of what we already do well. And there’s no reason why any neurosurgeon doing CEA at any hospital couldn’t do it using regional instead of general anesthesia.”


Scott Simon, M.D.Scott Simon, M.D.
Assistant Professor of Neurosurgery
PHONE: 717-531-3828
E-MAIL: ssimon@hmc.psu.edu
RESIDENCIES: Neurosurgery and General Surgery, Vanderbilt University Medical Center
MEDICAL SCHOOL: University of Chicago-Pritzker School of Medicine


References

  1. Kfoury E, Leng D, Hashemi H and Mukherjee D. Cardiac Morbidity of Carotid Endarterectomy Using Regional Anesthesia Is Similar to Carotid Stent Angioplasty. Vasc Endovascular Surg 2013;47: 599-602.
  2. Harbaugh RE, Patel A. Surgical Advances for Extracranial Carotid Stenosis. Neurosurgery 2014; 74: S83-91.
  3. Gürer O, Yapici F, Yapici N, Özler A, and Isik Ö. Comparison Between Local and General Anesthesia for Carotid Endarterectomy: Early and Late Results. Vasc Endovascular Surg 2012; 46: 131-138.

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