Local anaesthesia and propofol-fentanyl sedation for carotid artery surgery

In patients undergoing carotid artery surgery with local anaesthesia (LA), a sedative/analgesic pharmacological supplement is appropriate in most cases in order to provide comfort. This adjunct should not preclude continuous clinical neurological monitoring. The aim was to investigate if a combination of fentanyl and propofol to supplement LA would provide comfort for the patient, allow continuous clinical neurological monitoring and absence of difficulties for the anaesthetist, and good conditions for surgery, including insertion of a shunt if this should become necessary.

During a 1-year period low doses of propofol and fentanyl were used to supplement LA in 36 cases of carotid artery surgery in 34 consecutive patients. A shunt was only used if neurological dysfunction occurred. Data on haemodynamics, pulmonary gas exchange, clinical neurological monitoring, and subjective opinions from patients, surgeons and anaesthetists were obtained. Morbidity within 30 days was documented.

Conversion to general anaesthesia was undertaken in one patient, previously operated on the same artery, who became unconscious due to a stroke during manipulation of the artery before arteriotomy. No other adverse outcome was found within 30 days. In the remaining 35 cases the procedures were carried out under LA. Stump pressures below 50 mmHg were found in 17/35 cases. Intraoperative neurological dysfunction was detected in 10/35 cases (stump pressures between 23 and 60 mmHg). Shunting was easily performed, and rapidly relieved the neurologic symptoms in all these patients. Intraoperative respiratory and haemodynamic control was satisfactory. Ease of performance, including clinical neurological monitoring, was acknowledged by both anaesthetists and surgeons, and all 33 patients (35 operations) who were accessible for a postoperative interview stated that they would prefer the same regimen in the case of further surgery.

The number of cases in this open, uncontrolled study does not permit an evaluation of this anaesthetic and sedative technique in terms of neurological and cardiac outcome. Thus, we simply want to inform about our positive experiences regarding patient acceptance and ease of performance in all relevant respects when fentanyl and propofol are used to supplement LA for carotid artery surgery.