Not at all .

In our initial experience we did Carotid Endarterectomy with local or local regional anesthesia.

Currently we use to do:

General anesthesia with shunt in all patients, some we use patch (women or narrow carotid artery).

Both, local or general anesthesia have advantages or disadvantages .

Now i prefer general anesthesia.

I agree with you that general anesthesia is more confortable for surgeon without difference with local for the outcome of patients. But just a question...why shunt to all? is it really necessary? We adopt only stump pressure to cerebral monitorage and to choose when insert the shunt. So why use shunt to all?

Dear Emanuele, I agree that not all patients will require shunt but as we work in a teaching hospital with residents and interns, than for a standardization and reduce the risk of inaccurate reviews we chose this routine.

Dear Paulo, I understand your point of view. Many Thanks for your answer!

You are welcome !

We all know carotid endarterectomy may be performed with general, local or regional anesthesia.

In may opinion, regional anesthesia for cervical block is more comfortable when compared with the local infiltration anesthesia both for the patient and the surgeon. However, sometimes additional doses of local anesthetic injections may be required.

If the patient receives general anesthesia, I always use a shunt. I never rely on the preoperative MRI evaluation of the Willis polygon, the stump pressure, transcranial doppler USG, electroencephalography or cerebral oxymetry. Because none of these methods are as good as momentary neurologic status monitoring and it is not possible when the patient is asleep.

If the patient receives local or regional anesthesia I check the neurologic status of the patient for about 2 minutes after applying the clamps and if nothing happens, I continue with the procedure; otherwise I deploy a carotid shunt. I believe momentary neurologic real time monitoring is the gold standard method to check the adequacy of the intracerebral circulation.

I never perform eversion endarterectomy.

I use lidocaine injection to anesthetize the carotid bulb.

I always stabilize the distal media level inside the artery with 7.0 or 8.0 prolene suture.

Regardless of the diameter of the carotid artery I always close the arteriotomy with a patch. The patch can be dacron, PTFE, pericardium, xeno-patch or autologous saphenous vein. I place the patch beyond the distal media level stabilization point.

My clamp times are never shorter than 25 minutes. I do not hurry. Rather, I take my time for a flawless endarterectomy.

in my experience sometimes the cervical block or local anesthesia resulted in coughing fits to the patient, which required conversion to general anaestesia.

We noticed that some patients do not stand up to an hour and a half of operation and after twenty minutes into the CEA begin to show signs of distress, this is really similar discomfort under local anesthesia and or with cervical block.

I also do not run the routine pre-operative MRI, but it could be a mistake because you do not know anything about the intracranial circulation.

I agree that brain monitoring under local anesthesia / cervical block is the safest, but in my experience I have never found differences in stroke between monitoring with local anesthesia and the stump pressure, as we have also written to the 'article.

I honestly do not understand the use of the shunt in all patients, I put it on only when needed.

I agree on a long time for an adequate EAA as it is the result that counts not the speed.

Small changes in flow may affect brain areas not being evaluated even with awaken patient. In that case it would be better to have this flow decrease in a resting anesthetized brain, consuming little oxygen than a awake patient. I would go for general anesthesia. Also we have more comfort for the patient and for the surgeon.

Dear all, I agree with the most part of your answers. The impact of the choice of anesthesia on the outcome of CEA has been evaluated in a large-scale study of general anesthesia versus local anesthesia (GALA) and no significant differences between the two types of anesthesia have been found. In the real world, anesthesiologists usually choose the anesthesia they are most comfortable with, despite several differences between the two techniques, especially regarding intraoperative patient neurological monitoring. Local anesthesia has the advantage of direct neurological monitoring of the conscious patient; however, patients and surgeons may find CEA under regional anesthesia stressful. In contrast, when the patient is under general anesthesia, it may be more difficult to decide whether or not to insert a temporary carotid shunt. A number of techniques and monitors are available to detect cerebral ischemia and to assist in this decision, but none are totally effective.

In our institution (Azienda Ospedaliero Universitaria Careggi Florence Italy) we are familiar with a particular type of anesthesia that we introduced sometimes ago and that nowadays is the preferred choice in our center. This is a technique of general anesthesia, which allows clinical monitoring of neurological function during carotid clamping by reducing the hypnotic component of anesthesia although maintaining the analgesic one. This type of anesthesia, that we have named Cooperative patient general anesthesia (Co.PA.Ge.A.), shares with local anesthesia the advantage of continuous clinical monitoring of the patient and with general anesthesia the definitive airway control guaranteed by intubation of the trachea. Unfortunately we have not the numbers adequate to check if this third option is better than the other two methods in terms of outcome. However we found it so convenient for our purposes that the most part of our patients are now operated under cooperation in general anesthesia. Please, if you are interested, read the paper:

Bevilacqua S, et al. Anesthesia for Carotid Endarterectomy: The Third Option. Patient Cooperation During General Anesthesia. Anesth Analg 2009;108:1929–36.

You can find it, freely downloadable in my researchgate.

I agree with the comments from all above but especially from Dr Bevilacqua.

I would like to add that I intentionally during clamping under general anaesthesia artificially elevate the blood pressure to about 180-200 with my anaesthetic colleague to reduce/eliminate the need for shunting by stump pressure measurementsand retrograde flow assessments.

I agree with dr. Alexandre Martucci. Personally I prefer general anesthesia, but just for a my own personal confort. In addition, since there are no statistical differences between the different anesthetic techniques and the incidence of stroke, I prefer to operate on patients under general anesthesia. No difference in shunt use between general and local anesthesia in my experience, nor difference in stroke incidence. As dr. Sergio Bevilacqua, in a serie of patients I also used the general anesthesia with the awakening of patients for brain monitoring. However I did not find any advantage compared to other anesthetic techniques nor differences in stroke incidence. As remenber by dr. Kishore Sieunarine elevation of blood pressure to about 180-200 with is a good method to avoid shunt use, but not always necessary.

Increasing the blood pressure during CEA has only a psychologic effect on the operating surgeon. Low blood pressure or high blood pressure, both are the same. Body is a closed circuit, so increase of blood pressure has nothing to do.

I think this page might help you on it:

http://researchpedia.info/difference-between-general-anesthesia-and-local-anesthesia/

@Murat Ugurlucan....

Unfortunately this statement is both a generalisation and not correct under some circumstances.

A stenosis can be viewed as a flow limiting lesion,and if you reduce the radius of the vessel by 50%,the flow may drop by a factor of 4,for the same blood pressure applied.

Dropping the pressure across a stenosis can adversely affect cerebral blood flow,and this can easily be demonstrated with transcranial doppler or INVOS.