Carotid Endarterectomy Under Local Anesthesia: An Alternative Treatment for Carotid Stenosis

Purpose. Carotid artery stenosis accounts for approximately 10% of all ischemic strokes, causing significant morbidity and mortality. Historically the standard of care for surgical candidates for carotid stenosis was carotid endarterectomy, traditionally done under general anesthesia. As carotid stenting becomes an established less invasive modality of treatment, we investigated carotid endarterectomy under local anesthesia as an alternative option. Methods. We conducted a retrospective review of medical charts for patients undergoing carotid endarterectomy at a large community hospital from July 2007 to June 2010. 30-day postoperative myocardial infarctions and strokes were evaluated for patients undergoing carotid endarterectomy under local anesthesia, compared to carotid endarterectomy under general anesthesia. Carotid artery shunting and preoperative stroke were also evaluated as risk factors for postoperative myocardial infarction and stroke. Fisher exact tests were calculated to compare postoperative outcomes between patient groups. Results. A total of 407 carotid endarterectomies under local anesthesia and 256 carotid endarterectomies under general anesthesia were included in the analysis. Age, sex, and occurrence of preoperative stroke were similar between study groups. General anesthesia patients were more likely to receive a shunt (82% vs 11%, P\u3c.001). General anesthesia patients had higher rates of postoperative myocardial infarction (1.2% vs 0%, P=.057) and stroke (2.3% vs 0.7%, P=.095), but these differences were not statistically significant. Patients with a shunt also had non-significantly higher rate of postoperative stroke (2.3% vs 0.7%, P=.096). Conclusions. Our evidence suggests that carotid endarterectomy under local anesthesia can be an effective alternative for carotid stenosis with a possibly better safety profile than carotid endarterectomy under general anesthesia. Larger randomized studies are needed to further evaluate these complications

Carotid Endarterectomy Under Local Anesthesia: An Alternative Treatment for Carotid Stenosis

Purpose. Carotid artery stenosis accounts for approximately 10% of all ischemic strokes, causing significant morbidity and mortality. Historically the standard of care for surgical candidates for carotid stenosis was carotid endarterectomy, traditionally done under general anesthesia. As carotid stenting becomes an established less invasive modality of treatment, we investigated carotid endarterectomy under local anesthesia as an alternative option. Methods. We conducted a retrospective review of medical charts for patients undergoing carotid endarterectomy at a large community hospital from July 2007 to June 2010. 30-day postoperative myocardial infarctions and strokes were evaluated for patients undergoing carotid endarterectomy under local anesthesia, compared to carotid endarterectomy under general anesthesia. Carotid artery shunting and preoperative stroke were also evaluated as risk factors for postoperative myocardial infarction and stroke. Fisher exact tests were calculated to compare postoperative outcomes between patient groups. Results. A total of 407 carotid endarterectomies under local anesthesia and 256 carotid endarterectomies under general anesthesia were included in the analysis. Age, sex, and occurrence of preoperative stroke were similar between study groups. General anesthesia patients were more likely to receive a shunt (82% vs 11%, P\u3c.001). General anesthesia patients had higher rates of postoperative myocardial infarction (1.2% vs 0%, P=.057) and stroke (2.3% vs 0.7%, P=.095), but these differences were not statistically significant. Patients with a shunt also had non-significantly higher rate of postoperative stroke (2.3% vs 0.7%, P=.096). Conclusions. Our evidence suggests that carotid endarterectomy under local anesthesia can be an effective alternative for carotid stenosis with a possibly better safety profile than carotid endarterectomy under general anesthesia. Larger randomized studies are needed to further evaluate these complications

Modified “Trap Door” Approach for Thoracic Outlet Syndrome Complicated by Subclavian Artery Aneurysm

Arterial thoracic syndrome is a rare condition that usually presents in young patients with upper extremity thromboembolization. The traditional surgical approaches described are supraclavicular and transaxillary. We hereby present the case of a 46-year-old male with left arterial thoracic outlet syndrome and left subclavian artery aneurysm. We describe our technique in approaching his condition with a modified “trap door” approach

“Chimney” Graft Technique for Juxtarenal AAA Using Unibody Bifurcated Stent Graft

Juxtarenal abdominal aortic aneurysms in patients who are poor candidates for open repair present a challenge for the treating surgeon. With fenestrated aortic endografts currently not readily accessible, the alternative option would be aortic endograft using a “chimney” technique. We present a case report of an 84-year-old female who is a poor surgical candidate, presenting with symptomatic juxtarenal abdominal aortic aneurysm involving the left renal artery. Satisfactory repair was performed using an Endologix Powerlink endograft with chimney technique for the left renal artery. To our knowledge this is the second report of chimney graft using the Endologix Powerlink system

Posterior tibial artery aneurysm in a child with SMAD3 mutation

Peripheral arterial aneurysms in children are uncommon. We report a 6-year-old boy who developed a right posterior tibial artery aneurysm with symptoms including pain and pulsatile tenderness. His genetic testing revealed a SMAD3 mutation, a condition associated with familial aortic aneurysm, early-onset of osteoarthritis, and peripheral aneurysms. The posterior tibial artery aneurysm was treated with surgical resection and primary anastomosis. The patient remained free of symptoms or aneurysm recurrence in his tibial artery 2 years later. This represents the first reported case of pediatric tibial artery aneurysm linked to a SMAD3 mutation

Improved Results in the Management of Ruptured Abdominal Aortic Aneurysm May Not Be on the Basis of Endovascular Aneurysm Repair Alone

Recent improvement in the survival of patients presenting with a ruptured abdominal aortic aneurysm (rAAA) has been credited to endovascular aneurysm repair (EVAR). We present our clinical series in the management of rAAA from 2007 to 2011. A total of 55 consecutive patient charts were reviewed. Thirty-eight patients underwent EVAR, 17 of the 55 patients did not have favorable anatomy for EVAR. Nine of the 17 patients underwent standard open repair. Eight patients underwent a \u27hybrid repair\u27 defined as suprarenal aortic endovascular balloon control followed by open repair. Overall 30-day mortality for all 55 patients was 22%. Mortality for the patients managed by endovascular aortic aneurysm repair was 26% compared with 22% with open repair. There were no deaths in the eight patients undergoing the hybrid repair. Endovascular balloon control of the aorta followed by open rAAA repair in patients who are not candidates for rEVAR has produced good results in our experience. Improved results being reported in the management of rAAA may not be on the basis of endovascular repair alone

Carotid Endarterectomy Under Local Anesthesia Has Less Risk of Myocardial Infarction Compared to General Anesthesia: An Analysis of National Surgical Quality Improvement Program Database

Objectives As carotid endarterectomy (CEA) is being increasingly compared to carotid artery stenting and the best current medical management, it has become important to revisit variables that might affect the outcomes of the procedure. Multiple studies have evaluated the effect of anesthesia type on CEA with inconsistent results. Our study compared 30 day postoperative myocardial infarction (MI), stroke and mortality between CEA under local or regional anesthesia (LA) and CEA under general anesthesia (GA) utilizing National Surgical Quality Improvement Program (NSQIP) database. Methods All patients listed in NSQIP database that underwent CEA under GA and LA from 2005-2011 were included with the exception of patients undergoing simultaneous CEA and CABG. Postoperative MI, stroke, and death at 30 days were compared between the two groups using simple and multiple logistic regression. Results A total of 42,265 CEA cases were included. 37,502 (88.7%) were performed under GA and 4763 (11.3%) under LA. CEA under LA had a significantly decreased risk of 30 day postoperative MI when compared to CEA under GA (0.4% vs 0.86%; P = .012). No statistically significant differences were found in postoperative stroke or mortality ( Table). Conclusions CEA under LA carries a decreased risk of postoperative MI when compared to CEA under GA. Patients with multiple comorbidities at risk of postoperative MI should be considered for CEA under LA. Table Comparison of 30-day postoperative MI, stroke, and death for CEA under LA vs GA with and without adjustment for confounding factors CEA under LA (n = 4763)CEA under GA (n = 37,502)Unadjusted P valueAdjusted P value MI, No. (%) 20 (0.40) 323 (0.86) .002 .012 Stroke, No. (%) 66 (1.39) 592 (1.58) .318 .540 Death, No. (%) 32 (0.67) 315 (0.84) .227 .66