Hemodynamic Predictors And Changes During Carotid Endarterectomy Under Regional Anesthesia

Authors

  • Vera A. Silva Faculty of Medicine, University of Porto, Portugal https://orcid.org/0009-0004-7115-7184
  • Luís D. Gamas Department of Physiology and Surgery, Faculty of Medicine, University of Porto, Portugal; Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal https://orcid.org/0000-0002-9271-1170
  • Juliana Pereira-Macedo Faculty of Medicine, University of Porto, Portugal; Department of General Surgery, Centro Hospitalar do Médio-Ave, Vila Nova de Famalicão, Portugal https://orcid.org/0000-0001-9271-0277
  • Mariana Carreira Centro Hospitalar de Leiria, Portugal
  • Piotr Myrcha 1st Chair and Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland; Department of General, Vascular and Oncological Surgery, Masovian Brodnowski Hospital, 03-242 Warsaw, Poland https://orcid.org/0000-0002-6683-429X
  • José P. Andrade CINTESIS@RISE, RISE@Health, Faculty of Medicine, University of Porto, Portugal; Department of Biomedicine – Unity of Anatomy, Faculty of Medicine of the University of Porto, Portugal
  • André L. Moreira Department of Physiology and Surgery, Faculty of Medicine, University of Porto, Portugal; Cardiovascular R&D Centre – UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal https://orcid.org/0000-0002-2035-061X
  • João Rocha-Neves CINTESIS@RISE, RISE@Health, Faculty of Medicine, University of Porto, Portugal; Department of Biomedicine – Unity of Anatomy, Faculty of Medicine of the University of Porto, Portugal https://orcid.org/0000-0002-2656-8935

DOI:

https://doi.org/10.48729/pjctvs.502

Keywords:

carotid stenosis, neurologic exam, hemodynamic monitoring, awake test, locoregional anesthesia

Abstract

Objectives: Carotid endarterectomy (CEA) is the standard treatment for carotid stenosis, but it can lead to cerebral hypoperfusion and hemodynamic stroke. Regional anesthesia (RA) and light sedation allow continuous monitoring of intraoperative neurological function. However, the relationship between perioperative hemodynamic management and neurological dysfunction has yet to be thoroughly investigated. This study aims to identify hemodynamic patterns that are associated with intraoperative cerebral ischemia in CEA under RA.
Material and Methods: Patients who underwent CEA at an academic tertiary referral center between January 2012 and December 2019 were included. Cases were individuals who developed intraoperative neurological deficits (ND). Consecutive controls without ND were sampled in 1:1 ratio.
Results: 154 patients were included, 78.6% male, and mean age was 70.1±9.1 years. Cases were on average older than controls (72.0 ± 9.90 vs 68.3 ± 8.3 years, p=0.012). Baseline systolic blood pressure (SBP) values were higher in the ND group (154.6 ± 31.8 vs 141.8 ± 41.2 mmHg, p=0.035), alongside pulse pressure (98.1 ± 24.0 vs. 87.4 ± 32 mmHg, p=0.023). The ND group also had a statistically significant higher mean arterial pressure at the 3rd-minute post-clamp (108.3 ± 19.7 vs 101.1 ± 20.2 mmHg, p=0.028) and a smaller drop in SBP between the pre-clamp and the 1st and 3rd minutes post-clamp (11.95±16.19 vs. 19.79±24.01 mmHg, p=0.021 and 11.12±21.83 vs 19.42±26.78 mmHg, p=0.039, respectively).
Conclusions: Intraoperative ND showed no characteristic predictive pattern, besides higher SBP. Hemodynamic management could be key for preventing unwanted deficits.

Downloads

Download data is not yet available.

References

Ferro JM, Oliveira V, Melo TP, Crespo M, Lopes J, Fernandes e Fernandes J, et al. [Role of endarterectomy in the secondary prevention of cerebrovascular accidents: results of the European Carotid Surgery Trial (ECST)]. Acta Med Port. 1991;4(4):227-8.

Chaturvedi S. Carotid endarterectomy outcomes. What does the patient bring to the table? Neurology. 2018;91(17):769-70.

Howell SJ. Carotid endarterectomy. Br J Anaesth. 2007;99(1):119-31.

North American Symptomatic Carotid Endarterectomy Trial C, Barnett HJM, Taylor DW, Haynes RB, Sackett DL, Peerless SJ, et al. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med. 1991;325(7):445-53.

Sharpe RV, Dennis MJ, Nasim A, McCarthy MJ, Sayers RD, London NJ, Naylor AR. Dual antiplatelet therapy prior to carotid endarterectomy reduces post-operative embolisation and thromboembolic events: post-operative transcranial Doppler monitoring is now unnecessary. Eur J Vasc Endovasc Surg. 2010;40(2):162-7.

Gough MJ, Bodenham A, Horrocks M, Colam B, Lewis SC, Rothwell PM, et al. GALA: an international multicentre randomised trial comparing general anaesthesia versus local anaesthesia for carotid surgery. Trials. 2008;9:28.

Knappich C, Kuehnl A, Tsantilas P, Schmid S, Breitkreuz T, Kallmayer M, et al. Intraoperative Completion Studies, Local Anesthesia, and Antiplatelet Medication Are Associated With Lower Risk in Carotid Endarterectomy. Stroke. 2017;48(4):955-62.

Stoneham MD, Thompson JP. Arterial pressure management and carotid endarterectomy. Br J Anaesth. 2009;102(4):442-52.

Rocha-Neves J, Pereira-Macedo J, Ferreira A, Dias-Neto M, Andrade JP, Mansilha AA. Impact of intraoperative neurologic deficits in carotid endarterectomy under regional anesthesia. Scandinavian Cardiovascular Journal. 2021;55(3):180-6.

Pereira-Neves A, Rocha-Neves J, Fragao-Marques M, Duarte-Gamas L, Jacome F, Coelho A, et al. Red blood cell distribution width is associated with hypoperfusion in carotid endarterectomy under regional anesthesia. Surgery. 2021;169(6):1536-43.

Pereira-Macedo J, Lopes-Fernandes B, Duarte-Gamas L, Pereira-Neves A, Mourao J, Khairy A, et al. The Gupta Perioperative Risk for Myocardial Infarct or Cardiac Arrest (MICA) Calculator as an Intraoperative Neurologic Deficit Predictor in Carotid Endarterectomy. J Clin Med. 2022;11(2):16567.

Noto A, Sanfilippo F, De Salvo G, Crimi C, Benedetto F, Watson X, et al. Noninvasive continuous arterial pressure monitoring with Cleansight during awake carotid endarterectomy: A prospective observational study. Eur J Anaesthesiol. 2019;36(2):144-52.

Bartková, A. Prospectivní analýza subtypu a rizikových faktorů i schémiček cévní mozkové příhody u dospělých do 50 let. Česk Slov Neurol N; 73/106(2): 143-149. 2010.

Agha R, Borrelli M, Vella-Baldacchino M, Thavayogan R, Orgill D, Group S. The STROCSS statement: Strengthening the Reporting of Cohort Studies in Surgery. Int J Surg. 2017;46:198-202.

Oates CP, Naylor AR, Hartshorne T, Charles SM, Fall T, Humphries K, et al. Joint recommendations for reporting carotid ultrasound investigations in the United Kingdom. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2009;37(3):251-61.

Poldermans D, Bax JJ, Boersma E, De Hert S, Eeckhout E, Fowkes G, et al. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: the Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). Eur J Anaesthesiol. 2010;27(2):92-137.

Duarte-Gamas L, Pereira-Neves A, Sousa J, Sousa-Pinto B, Rocha-Neves J. The Diagnostic Accuracy of Intra-Operative Near Infrared Spectroscopy in Carotid Artery Endarterectomy Under Regional Anaesthesia: Systematic Review and Meta-Analysis. (1532-2165 (Electronic)).

Pennekamp CV, Bots MI Fau - Kappelle U, Kappelle IJ Fau - Moll FL, Moll FI Fau - de Borst GI, de Borst GL. The value of near-infrared spectroscopy measured cerebral oximetry during carotid endarterectomy in perioperative stroke prevention. A review. (1532-2165 (Electronic)).

Rocha-Neves JA-O, Pereira-Macedo J, Moreira AL, Oliveira-Pinto JP, Afonso G, Mourao J, et al. Efficacy of near-infrared spectroscopy cerebral oximetry on detection of critical cerebral perfusion during carotid endarterectomy under regional anesthesia. (0301-1526 (Print)).

Lobo M MJ, Afonso G. Carotid endarterectomy: review of 10 years of practice of general and locoregional anesthesia in a tertiary care hospital in Portugal. Braz J Anaesthesiol. 2015;65(4):249-54.

Alves-Ferreira J, Rocha-Neves J, Dias-Neto M, Braga SF. Poor long-term outcomes after carotid endarterectomy: a retrospective analysis of two portuguese centers. Scand Cardiovasc J. 2019;53(5):266-73.

Lobo M, Mourao J, Afonso G. Carotid endarterectomy: review of 10 years of practice of general and locoregional anesthesia in a tertiary care hospital in Portugal. Braz J Anaesthesiol. 2015;65(4):249-54.

Naylor R, Ranmer B, Ancetti S, de Borst GI, De Carlo M, Halliday A, et al. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg. 2023;65(1):7-111.

Bots ML, Fassaert LMM, Kappelle U, de Groot MCH, Haijema S, Bonati LH, et al. Intra-Operative Hypotension is a Risk Factor for Post-operative Silent Brain Ischaemia in Patients With Pre-operative Hypertension Undergoing Carotid Endarterectomy. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2020;59(4):526-34.

Aleksic M, Heckenkamp J, Gawenda M, Reichert V, Brunkwall J. Evaluation of changes of systemic blood pressure and shunt incidence in CEA. Eur J Vasc Endovasc Surg. 2007;34(5):540-5.

Serne EH, Rauwerda JA, Wisselnik W, Visser MC, Roos YB, Smulders YM. [Blood pressure control in patients with a symptomatic carotid artery stenosis]. Ned Trjúschr Geneeski. 2008;152(48):2617-22.

Bouri S, Thapar A, Shalhoub J, Jayasooniya G, Fernando A, Franklin II, Davies AH. Hypertension and the post-carotid endarterectomy cerebral hyperperfusion syndrome. Eur J Vasc Endovasc Surg. 2011;41(2):229-37.

Joseph J, P MN, Shah MI, Sivaprakasan M. Arterial compliance probe for cuffless evaluation of carotid pulse pressure. PloS One. 2018;13(8):e0202480.

MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. European Carotid Surgery Trialists Collaborative Group. Lancet. 1991;337(8752):1235-43.

Sagaro GG, Di Canio M, Amenta F. Correlation between body mass index and blood pressure in seafarers. Clin Exp Hypertens. 2021;43(2):189-95.

Goldstein LB, McCrory DC, Landsman PB, Samsa GP, Ancukiewicz M, Oddone EZ, Matchar DB. Multicenter review of preoperative risk factors for carotid endarterectomy in patients with ipsilateral symptoms. Stroke. 1994;25(6):1116-21.

Tseng YC, Lucas SJ, Atkinson G, Willie CK, Ainslie PN. Fundamental relationships between arterial baroreflex sensitivity and dynamic cerebral autoregulation in humans. J Appl Physiol (1985). 2010;108(5):1162-8.

Teixeira SC, Madureira JB, Azevedo EJ, Castro PM. Ageing affects the balance between central and peripheral mechanisms of cerebrovascular regulation with increasing influence of systolic blood pressure levels. Eur J Appl Physiol. 2019;119(2):519-29.

Ma H, Guo ZN, Jin H, Yan X, Liu J, Lv S, et al. Preliminary Study of Dynamic Cerebral Autoregulation in Acute Ischemic Stroke: Association With Clinical Factors. Front Neurol. 2018;9:1006.

Semenyutin VB, Asaturyan GA, Nikiforova AA, Aliev VA, Panuntsov GK, Iblyamimov VB, et al. Predictive Value of Dynamic Cerebral Autoregulation Assessment in Surgical Management of Patients with High-Grade Carotid Artery Stenosis. Front Physiol. 2017;8:872.

Sigaudo-Roussel D, Evans DH, Naylor AR, Panerai RB, London NL, Bell P, Gaunt ME. Deterioration in carotid baroreflex during carotid endarterectomy. J Vasc Surg. 2002;36(4):793-8.

Drummond JC. Blood Pressure and the Brain: How Low Can You Go? Anesth Analg. 2019;128(4):759-71.

Czosnyka M, Balesteri M, Steiner L, Smielewski P, Hutchinson PJ, Matta B, Pickard JD. Age, intracranial pressure, autoregulation, and outcome after brain trauma. J Neurosurg. 2005;102(3):450-4.

Ajduk M, Tudoric I, Sarifja M, Pavic P, Oremus Z, Held R, Patrij L. Effect of carotid sinus nerve blockade on hemodynamic stability during carotid endarterectomy under local anesthesia. J Vasc Surg. 2011;54(2):386-93.

Thrasher TN. Unloading arterial baroreceptors causes neurogenic hypertension. Am J Physiol Regul Integr Comp Physiol. 2002;282(4):R1044-53.

Rocha-Neves JM, Pereira-Macedo J, Dias-Neto MF, Andrade JP, Manalina AA. Benefit of selective shunt use during carotid endarterectomy under regional anesthesia. Vascular. 2020;28(5):505-12.

Aziz F, Lehman EB, Reed AB. Increased Duration of Operating Time for Carotid Endarterectomy Is Associated with Increased Mortality. Ann Vasc Surg. 2016;36:166-74.

Martinez-Martinez E, Souza-Neto FV, Jimenez-Gonzalez S, Cachofeiro V. Oxidative Stress and Vascular Damage in the Context of Obesity: The Hidden Guest. Antioxidants (Basel). 2021;10(3):496.

Duarte-Gamas L, Pereira-Neves A, Sousa J, Sousa-Pinto B, Rocha-Neves J. The Diagnostic Accuracy of Intra-operative Near Infrared Spectroscopy in Carotid Artery Endarterectomy Under Regional Anaesthesia: Systematic Review and Meta-Analysis. Eur J Vasc Endow Soc Surg. 2021;62(4):522-31.

Roque-Carvallino B, Pereira-Macedo J, Arantes M, Sousa J, Romana-Dias L, Ribeiro H, et al. Basal Ganglias influence on awake test in carotid endarterectomy. Eur J Radiol. 2024;181:111812.

Downloads

Published

29-04-2025

How to Cite

1.
Silva VA, D. Gamas L, Pereira-Macedo J, Carreira M, Myrcha P, Andrade JP, L. Moreira A, Rocha-Neves J. Hemodynamic Predictors And Changes During Carotid Endarterectomy Under Regional Anesthesia. Rev Port Cir Cardiotorac Vasc [Internet]. 2025 Apr. 29 [cited 2025 May 4];32(1):13-2. Available from: https://pjctvs.com/index.php/journal/article/view/502

Issue

Section

Original Articles

Categories

Most read articles by the same author(s)

1 2 > >>