title: Examination of regional anesthesia for carotid endarterectomy.
abstract: OBJECTIVE
  Carotid endarterectomy is the most effective treatment for reducing the risk of stroke in patients with significant carotid stenosis. Few studies have focused on the failure rate of regional anesthesia.
  
  
  METHODS
  Data of all patients undergoing carotid endarterectomy (June 2009 to December 2014) in a single center were collected. Combined deep and superficial cervical plexus block or superficial plexus block alone was used according to the attending anesthesiologist's choice and the patient's characteristics (eg, dual antiplatelet or anticoagulation therapy). Intraoperative remifentanil (0.025-0.05 μg/kg/min) was administered to maintain an adequate level of comfort, responsiveness, and cooperation. General anesthesia was planned only in the case of major contraindications or the patient's refusal of locoregional anesthesia. The primary end point of our study was the incidence of intraoperative conversion from locoregional to general anesthesia.
  
  
  RESULTS
  A total of 2463 carotid endarterectomies were included in the analysis. Regional anesthesia was initially chosen in 2439 patients, whereas 24 patients received planned general anesthesia. In seven cases, regional anesthesia was converted to general anesthesia because of severe agitation of the patient (before clamping in four cases, after carotid clamping in two cases, and after declamping in one case). A shunt was used in 302 patients (12.3%) because of neurologic deterioration at the carotid clamping test. Intraoperative complications were emergent repeated surgical procedures in 13 cases (0.53%) because of acute neurologic deterioration, 1 intraoperative acute myocardial infarction (0.04%), and 3 cases (0.04%) of hemodynamically relevant supraventricular tachyarrhythmia. No intraoperative death occurred. In-hospital mortality was 0.12% (three patients). Major stroke occurred in 23 patients (0.93%); minor stroke occurred in 16 patients (0.65%). The combined stroke and death rate was 1.62% (40 patients).
  
  
  CONCLUSIONS
  In our practice, carotid endarterectomy under regional anesthesia is safe and associated with a very low rate of conversion to general anesthesia.
authors.affiliation: Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy. Electronic address: pasin.laura@hsr.it.
authors.forename: Laura
authors.initials: L
authors.lastname: Pasin
authors.affiliation: Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Pasquale
authors.initials: P
authors.lastname: Nardelli
authors.affiliation: Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Landoni
authors.affiliation: Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Guglielmo
authors.initials: G
authors.lastname: Cornero
authors.affiliation: Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Silvio
authors.initials: S
authors.lastname: Magrin
authors.affiliation: Vita-Salute San Raffaele University, Milan, Italy.
authors.forename: Yamume
authors.initials: Y
authors.lastname: Tshomba
authors.affiliation: Vita-Salute San Raffaele University, Milan, Italy; Department of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Chiesa
authors.affiliation: Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
authors.forename: Alberto
authors.initials: A
authors.lastname: Zangrillo
mesh_terms: D000701:Analgesics, Opioid / Q000008:administration & dosage; D000768:Anesthesia, General; D016893:Carotid Stenosis / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D002561:Cerebrovascular Disorders / Q000209:etiology; D066008:Cervical Plexus Block / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage; D007558:Italy; D009203:Myocardial Infarction / Q000209:etiology; D010880:Piperidines / Q000008:administration & dosage; D000077208:Remifentanil; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013617:Tachycardia, Supraventricular / Q000209:etiology; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000701:Analgesics, Opioid; D006993:Hypnotics and Sedatives; D010880:Piperidines; D000077208:Remifentanil