Locoregional versus general anesthesia in carotid surgery: is there an impact on perioperative myocardial ischemia? Results of a prospective monocentric randomized trial.
OBJECTIVE
The incidence of cardiac morbidity and mortality in patients who undergo carotid surgery ranges from 0.7% to 7.1%, but it still represents almost 50% of all perioperative complications. Because no data are available in literature about the impact of the anesthetic technique on such complications, a prospective randomized monocentric study was undertaken to evaluate the role of local anesthesia (LA) and general anesthesia (GA) on cardiac outcome.


METHODS
From November 1995 to February 1998, 107 patients were classified by the cardiologist as cardiac patients (IHD; history of myocardial infarction, previous myocardial revascularization procedures, or myocardial ischemia documented by means of positive electrocardiogram [ECG] stress test results) or noncardiac patients (NIHD; no history of chest pain or negative results for an ECG stress test). The patients were operated on after the randomization for the type of anesthesia (general or local). Continuous computerized 12-lead ECG was performed during the operative procedure and 24 hours postoperatively. The end points of the study were ECG modifications (upsloping or downsloping more than 2 mm) of the sinus tachycardia (ST) segment.


RESULTS
Fifty-five patients were classified as IHD, and 52 were classified as NIHD. Twenty-seven of the 55 IHD patients (49%) and 24 of 52 NIHD patients (46%) were operated on under GA. Thirty-six episodes of myocardial ischemia occurred in 22 patients (20.5%). Episodes were slightly more frequent (58%) and longer in the postoperative period (intraoperative, 10 +/- 5 min; postoperative, 60 +/- 45 min; P <. 001). As expected, the prevalence of myocardial ischemia was higher in the group of cardiac patients than in noncardiac group (15 of 55 patients [27%] vs 7 of 52 patients [13%]; P <.02). By comparing the two anesthetic techniques in the overall population, we found a similar prevalence of patients who had myocardial ischemia (GA, 12 of 52 [23%]; LA, 10 of 55 [18%]; P = not significant) and a similar number of ischemic episodes per patient (GA, 1.5 +/- 0.4; LA, 1.8 +/- 0.6; P = not significant). Episodes of myocardial ischemia were similarly distributed in intraoperative and postoperative periods in both groups. It is relevant that under GA, IHD patients represent most of the population who suffered myocardial ischemia (83%). On the contrary, in the group of patients operated on under LA, the prevalence was equally distributed in the two subpopulations.


CONCLUSIONS
The results confirm the different hemodynamic impact of the two anesthetic techniques. Patients who received LA had a rate of myocardial ischemia that was half that of patients who had GA. The small number of cardiac complications do not permit us to make any definitive conclusion on the impact of the two anesthetic techniques on early cardiac morbidity, but the relationship between perioperative ischemic burden and major cardiac events suggests that LA can be used safely, even in high-risk patients undergoing carotid endarterectomy.
I Cattedra di Chirurgia Vascolare, Cattedra di Anestesiologia e Rianimazione, and I Cattedra di Cardiologia, the University of Rome "La Sapienza," Rome, Italy.
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D000368:Aged; D015760:Alfentanil; D000768:Anesthesia, General; D000772:Anesthesia, Local; D018686:Anesthetics, Intravenous; D000779:Anesthetics, Local; D002045:Bupivacaine; D004562:Electrocardiography; D016894:Endarterectomy, Carotid; D005260:Female; D006801:Humans; D007432:Intraoperative Period; D008297:Male; D016343:Monitoring, Intraoperative; D017202:Myocardial Ischemia / Q000453:epidemiology* / Q000517:prevention & control; D011184:Postoperative Period; D011446:Prospective Studies; D012307:Risk Factors
D018686:Anesthetics, Intravenous; D000779:Anesthetics, Local; D015760:Alfentanil; D002045:Bupivacaine