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• W2891839175 abstract "STROKE CURRENTLY remains the second cause of death among all patients with cardiovascular disease.1Go AS Mozaffarian D Roger VL et al.Heart disease and stroke statistics – 2014 update: A report from the American Heart Association.Circulation. 2014; 129: e28-e92Crossref PubMed Scopus (4494) Google Scholar Carotid endarterectomy (CEA) is a safe and effective surgical technique that lowers the risk of ischemic stroke in patients with carotid artery stenosis secondary to atherosclerotic disease.2Kerman WN Ovbiagele B Black HR American Heart Association Stroke CouncilCouncil on Cardiovascular and Stroke NursingCouncil on Clinical Cardiology, and Council on Peripheral Vascular DiseaseGuidelines for the prevention of stroke in patients with stroke and transient ischemic attack: A guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke. 2014; 45: 2160-2236Crossref PubMed Scopus (3011) Google Scholar CEA is associated with improved neurologic and cognitive function and quality of life. Nevertheless, despite significant achievements in perioperative management strategies for patients undergoing CEA, the rate of major complications such as ischemic stroke, myocardial infarction, and mortality remains high.3Lichtman JH Jones MR Leifheit EC et al.Carotid endarterectomy and carotid artery stenting in the US Medicare population, 1999 - 2014.JAMA. 2017; 318: 1035-1046Crossref PubMed Scopus (96) Google Scholar Numerous intraoperative factors are responsible for the development of complications. These include, but are not limited to, intraoperative hypotension, hypertension, and cerebral embolization. In an attempt to prevent morbidity and mortality, researchers are working toward determining the optimal anesthetic technique. At present, the safety of local/regional anesthesia (RA) versus that of general anesthesia (GA) for patients undergoing CEA is a debatable topic. The general anesthesia versus local anesthesia for carotid surgery (GALA) trial is a landmark study in this field.4Lewis SC Warlow CP et al.GALA Trial Collaborative GroupGeneral anaesthesia versus local anaesthesia for carotid surgery (GALA): A multicentre, randomised controlled trial.Lancet. 2008; 372: 2132-2142Abstract Full Text Full Text PDF PubMed Scopus (475) Google Scholar In this trial, 3,526 patients with symptomatic or asymptomatic carotid stenosis were randomly assigned to surgery under GA or local anesthesia. The primary outcome was the occurrence of stroke, myocardial infarction, or death up to 30 days after surgery. The authors showed that the primary outcome occurred in 4.8% and 4.5% patients who underwent surgery under GA and local anesthesia, respectively. There were no significant differences in the quality of life and length of hospitalization after surgery. However, the GALA trial also has several limitations. The majority of included patients had an American Society of Anesthesiologists performance status of II. Moreover, the number of patients with comorbidities (diabetes, chronic lung disease, coronary heart disease) also was small. In general, the study did not address the following question: Does RA decrease cardiovascular complications in high-risk patients? Fewer than 10% of patients in both groups exhibited a high surgical risk. Considering the aging population, the increasing number of comorbidities, and evolving anesthetic management techniques, there is an urgent need for reassessment of the risks and benefits of RA and GA for carotid surgery. In the current issue of the Journal of Cardiothoracic and Vascular Anesthesia, Malik et al. published their study on the effects of RA and GA on 30-day mortality (primary outcome) and various complications in patients who underwent CEA.5Malik OS, Brovman EY, Urman RD. The use of regional or local anesthesia for carotid endarterectomies may reduce blood loss and pulmonary complications. J Cardiothorac Vasc Anesth 2018 [in press]Google Scholar They conducted a retrospective study using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) dataset and evaluated patients undergoing CEA at multiple university- and community-based institutions. A total of 43,463 patients were identified, 22,854 of whom were subjected to propensity matching (3,809 patients in the RA group and 19,045 patients in the GA group) after exclusion of those with missing data. Patients in the RA group underwent surgery under RA administered by an anesthesiologist or the surgeon, with monitored anesthesia care and local infiltration. The results showed that the use of RA lowered the risk of postoperative pneumonia and reduced the need for perioperative blood transfusion, although there were no differences in the mortality rate. We would like to applaud the authors for the excellent results. Their findings are in agreement with those of Liu et al., who analyzed NSQIP data from 2005 to 2012 and found significant differences in the rates of unexpected intubation (1.21% v 0.55%, respectively, p = 0.001) and myocardial infarction (0.8% v 0.35%, respectively, p = 0.039) between the GA and RA groups.6Liu J Martinez-Wilson H Neuman MD et al.Outcome of carotid endarterectomy after regional anesthesia versus general anesthesia – a retrospective study using two independent databases.Transl Perioper Pain Med. 2014; 1: 14-21PubMed Google Scholar In addition, the GA group exhibited a significantly higher rate of aspiration than did the RA group (0.61% v 0.19%, respectively, p = 0.014). Recent evidence has suggested that avoidance of endotracheal intubation potentially may decrease pulmonary complications in patients undergoing different types of vascular surgeries.7Smith LM Cozowicz C Uda Y Memtsoudis SG et al.Neuraxial and combined neuraxial/general anesthesia compared to general anesthesia for major truncal and lower limb surgery: A systematic review and meta-analysis.Anesth Analg. 2017; 125: 1931-1945Crossref PubMed Scopus (61) Google Scholar There are several mechanisms by which GA can cause pulmonary complications. The residual effects of neuromuscular blocking agents may be responsible for hypoxia and subsequent intubation in the intensive care unit after surgery. Mechanical ventilation causes disturbances in the pulmonary physiology, leading to atelectasis and hypoventilation. These effects may be more pronounced in patients with a preexisting lung pathology, particularly chronic obstructive pulmonary disease, which is considered an important risk factor for adverse postoperative outcomes.8Ponomarev D Kamenskaya O Klinkova A et al.Chronic lung disease and mortality after cardiac surgery: A prospective cohort study.J Cardiothorac Vasc Anesth. 2018; 32 (Dec 11 [E-pub ahead of print]): 2241-2245Abstract Full Text Full Text PDF Scopus (8) Google Scholar The mechanism by which RA lowers the rate of perioperative blood transfusion merits further investigation. There are several limitations of the study by Malik et al. that need to be considered during interpretation of the results; the majority are associated with the retrospective design of the study. First, the NSQIP database collects limited data on comorbidities that can influence the outcomes of CEA. Second, the rate of conversion from RA to GA, which results in an additional risk for the patient, cannot be captured from the database. Third, the incidence of pneumonia may have been underestimated or overestimated because the definition of pneumonia was not standardized. Fourth, data on the anesthetics used and their dosages for both RA and GA were not available. Nevertheless, the study highlights the necessity of future research in this field. The execution of a large-scale, randomized, multicenter study is not an easy task, and several issues need to be considered before planning one. First, the surgical technique and indications for the use of shunts should be optimized. The choice of anesthetic (volatile or total intravenous) for patients undergoing CEA also is an important factor. In a recent study, Kuzkov et al. showed that, compared with propofol anesthesia, volatile induction and maintenance of anesthesia with sevoflurane may preserve oxygenation in the contralateral hemisphere and improve early postoperative cognitive function.9Kuzkov VV Obraztsov MY Ivashchenko OY et al.Total intravenous vs. volatile induction and maintenance of anesthesia in elective carotid endarterectomy: Effects on cerebral oxygenation and cognitive functions.J Cardiothorac Vasc Anesth. 2018; 32: 1701-1708Abstract Full Text Full Text PDF Scopus (14) Google Scholar Therefore, the anesthetic management of patients receiving GA should be standardized. There is some evidence (mostly from cardiac surgery studies) that the type of anesthesia can influence the long-term results; therefore, a follow-up period of a minimum of 1 year seems reasonable. Considering recent data on the detrimental effects of perioperative hypotension on the clinical outcomes of patients undergoing noncardiac surgery, perioperative hemodynamic management should be the same for all patients. Last, but not least, according to modern guidelines, patients with systemic atherosclerosis and cardiovascular diseases should receive optimal medical treatment (renin–angiotensin–aldosterone system blockers, beta-blockers, antiplatelet agents, statins) to prevent disease progression, improve quality of life, and increase survival. On the other hand, renin-angiotensin blockade is associated with increased mortality in patients undergoing noncardiac surgery.10Lomivorotov VV Efremov SM Abubakirov MN et al.Perioperative management of cardiovascular medications.J Cardiothorac Vasc Anesth. 2018; 32: 2289-2302Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Because there is no strong evidence that supports the perioperative use of these drugs, this would become a major limitation of future trials. Thus, planning and conducting a large, international, multicenter study will require the consideration of several factors that can affect the clinical outcomes. On the other hand, a pragmatic attitude toward the execution of such a trial will only lead to negative results. The Use of Regional or Local Anesthesia for Carotid Endarterectomies May Reduce Blood Loss and Pulmonary ComplicationsJournal of Cardiothoracic and Vascular AnesthesiaVol. 33Issue 4PreviewOver 150,000 carotid endarterectomy (CEA) procedures are performed each year. Perioperative anesthetic management may be complex due to multiple patient and procedure-related risk factors. The authorsaimed to determine whether the use of general anesthesia (GA), when compared with regional anesthesia (RA), would be associated with reduced perioperative morbidity and mortality in patients undergoing a CEA. Full-Text PDF" @default.
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• W2891839175 title "Regional Versus General Anesthesia for Carotid Endarterectomy: Do We Need Another Randomized Trial?" @default.
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