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Staged anesthesia for combined carotid and coronary artery revascularization: a different approach
Samia Madi-Jebara1, Alexandre Yazigi, Ghassan Sleilaty
1Department of Anesthesiology and Critical Care, Hotel Dieu de France Hospital, Beirut, Lebanon.
Insights
This study presents a staged anesthetic approach for combined coronary artery bypass graft (CABG) and carotid endarterectomy (CEA) surgery. The technique successfully managed patients, offering an alternative for complex cases with no hospital mortality.
Area of Science:
- Cardiovascular Surgery
- Neurosurgery
- Anesthesiology
Background:
- Combined coronary artery bypass graft (CABG) and carotid endarterectomy (CEA) surgery aims to reduce stroke risk in patients with carotid stenosis.
- The optimal anesthesia for CEA during combined procedures remains debated, with regional anesthesia offering neurological monitoring advantages.
Purpose of the Study:
- To describe and evaluate a staged anesthetic approach combining regional anesthesia for CEA followed by general anesthesia for CABG.
- To improve neurologic monitoring and potentially avoid temporary shunting during combined CABG and CEA.
Main Methods:
- A prospective, nonrandomized case series of twenty patients undergoing combined CEA and CABG.
- A staged anesthetic technique involving regional anesthesia (deep and superficial cervical plexus blocks) for CEA, followed by general anesthesia and endotracheal intubation for CABG.
Main Results:
- All CEA and CABG procedures were completed successfully without the need for anesthetic conversion.
- No neurologic events occurred during CEA, and no hospital mortality was observed.
- One patient experienced a reversible ischemic stroke postoperatively.
Conclusions:
- The described staged anesthetic approach is a viable alternative for patients undergoing combined CABG and CEA surgery.
- This technique facilitates improved neurologic monitoring during CEA in complex surgical cases.
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.
Design:
Prospective nonrandomized case series.
Setting:
University hospital.
Participants:
Twenty patients scheduled for combined CEA and CABG surgery underwent a "staged" anesthetic approach from January to December 2004.
Interventions:
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.
Measurements And Main 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.
