title: Staged anesthesia for combined carotid and coronary artery revascularization: a different approach.
abstract: OBJECTIVE
  Combined coronary artery bypass graft (CABG) surgery and carotid endarterectomy (CEA) are performed in an attempt to reduce the risk of postoperative stroke after CABG surgery in patients with significant or symptomatic carotid artery stenosis. The choice between regional and general anesthesia for CEA is still under debate. Regional anesthesia offers an excellent monitoring technique of the neurologic status of the awake patient during carotid clamping. In an attempt to improve monitoring of the neurologic status and avoid the use of temporary shunting in patients undergoing the combined procedure, a different approach is described combining regional anesthesia for CEA followed immediately by general anesthesia for CABG surgery.
  
  
  METHODS
  Prospective nonrandomized case series.
  
  
  METHODS
  University hospital.
  
  
  METHODS
  Twenty patients scheduled for combined CEA and CABG surgery underwent a "staged" anesthetic approach from January to December 2004.
  
  
  METHODS
  Pulmonary, femoral artery, and urinary catheters were inserted under local anesthesia. A deep cervical plexus block was then performed and supplemented by a superficial cervical plexus block. The patient was draped for standard combined CEA and CABG surgery. CEA was then performed using standard techniques. Without altering the surgical field, general anesthesia was given and endotracheal intubation performed following the successful CEA. Coronary revascularization was then completed.
  
  
  RESULTS
  CEA and CABG surgery were completed successfully in all patients. There was no need for conversion from local to general anesthesia. Endotracheal intubation was easily performed in all patients. There was no hospital mortality in this series. No neurologic events were observed during the CEA. A reversible ischemic stroke, ipsilateral to the CEA, occurred postoperatively on awakening from CABG surgery in 1 patient.
  
  
  CONCLUSIONS
  This staged anesthetic approach for combined CABG and CEA surgery is an alternative in this complex subset of patients.
authors.affiliation: Department of Anesthesiology and Critical Care, Hotel Dieu de France Hospital, Beirut, Lebanon.
authors.forename: Samia
authors.initials: S
authors.lastname: Madi-Jebara
authors.forename: Alexandre
authors.initials: A
authors.lastname: Yazigi
authors.forename: Ghassan
authors.initials: G
authors.lastname: Sleilaty
authors.forename: Fadia
authors.initials: F
authors.lastname: Haddad
authors.forename: Gemma
authors.initials: G
authors.lastname: Hayek
authors.forename: Georges
authors.initials: G
authors.lastname: Tabet
authors.forename: Ramzi
authors.initials: R
authors.lastname: Ashoush
authors.forename: Bechara
authors.initials: B
authors.lastname: Asmar
authors.forename: Issam
authors.initials: I
authors.lastname: Rassi
authors.forename: Victor A
authors.initials: VA
authors.lastname: Jebara
mesh_terms: D000368:Aged; D000765:Anesthesia, Conduction / Q000379:methods*; D000768:Anesthesia, General / Q000379:methods*; D016893:Carotid Stenosis / Q000601:surgery*; D002572:Cervical Plexus / Q000187:drug effects; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000379:methods*; D003327:Coronary Disease / Q000601:surgery*; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal / Q000379:methods; D008297:Male; D009407:Nerve Block / Q000379:methods; D011183:Postoperative Complications / Q000209:etiology / Q000517:prevention & control; D011446:Prospective Studies; D020521:Stroke / Q000209:etiology / Q000517:prevention & control; D016896:Treatment Outcome