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J Vasc Surg. 2023 Feb; 77(2): 555–558.
Published online 2022 Oct 21. doi:10.1016/j.jvs.2022.09.026
PMCID: PMC9585845
PMID: 36280194
Veena Mehta, MD,a,∗ Peyton Tharp, BS,b Courtney Caruthers, BS,b Agenor Dias, MD,c and Mathew Wooster, MDc
Author information Article notes Copyright and License information PMC Disclaimer
Abstract
Objective
Hospital resource use is under constant review, and the extent and intensity of postoperative care requirements for vascular surgical procedures is particularly relevant in the setting of the coronavirus disease 2019 pandemic and its impact on staffed intensive care unit (ICU) beds. We sought to evaluate the feasibility of regional anesthesia (RA) and low-intensity postoperative care for patients undergoing transcarotid artery revascularization (TCAR) at our institution.
Methods
All patients undergoing TCAR at a single institution from 2018 to 2020 were reviewed. Perioperative management (anticoagulation and antiplatelet therapy, hemodynamic monitoring, neurovascular examination, nursing instructions) was standardized by use of an institutional protocol. Anesthetic modality was at the surgeon’s preference. Patients were transferred to a postanesthesia care unit for 2hours followed by the step-down unit, to a postanesthesia care unit for 4hours followed by the floor, or alternatively transferred to the ICU. Intravenous (IV) blood pressure medications could be administered at all environments except the floor. Recovery location and length of stay were recorded.
Results
A total of 83 patients underwent TCAR during the study period. The mean age 72± 9years and 59% were male. Thirty-six percent were symptomatic. RA was used for 84% with none converted to general anesthesia (GA) intraoperatively. Postoperatively, 7 of the 83 patients (8%) included in this study were monitored in an ICU overnight (decided perioperatively), mostly for patients with prior neurological symptoms, but in 1 case for postoperative neurological event and in another owing to pulseless electrical activity arrest. Six patients required IV antihypertensives and eight required IV vasoactive support postoperatively. The mean length of ICU stay was 3.7± 5.1days. The mean length of hospital stay for all patients was 2.4± 3.3days. The length of stay for patients undergoing TCAR with GA was higher than those undergoing TCAR with RA (4.2± 4.9days vs 1.4± 1.2days, respectively; P= .066). The incidence of stroke, death, and myocardial infarction was 2.4%. There was one postoperative stroke considered to be a recrudescence of prior stroke, and one respiratory arrest fatality in a frail patient with neck hematoma both of whom were treated under GA.
Conclusions
Using perioperative care protocols, TCAR can safely be performed while avoiding both GA and an ICU stay in most patients.
Keywords: TCAR, Carotid stenosis, Anesthesia type, Carotid stenting
Article Highlights
•
Type of Research: Single-center, retrospective cohort study
•
Key Findings: Patients treated with transcarotid artery revascularization (TCAR) using regional anesthesia had low rates of intensive care unit admission postoperatively (7%), and compared with patients undergoing TCAR with general anesthesia had a shorter overall length of hospital stay (1.4days vs 4.2days) and lower rates of postoperative myocardial infarction, stroke, and death (0% vs. 2.4%).
•
Take Home Message: TCAR can safely be performed while avoiding both general anesthesia and an intensive care unit stay in most patients.
Transcarotid artery revascularization (TCAR) has emerged as a technique for treating carotid artery stenosis, a significant cause of ischemic stroke, and has significant advantages in patients with high lesions, prior neck surgery or radiation, and uses a flow reversal mechanism to decrease the risk of embolic stroke. Several studies have compared patient outcomes in TCAR versus carotid endarterectomy (CEA) and found overall equivalent outcomes in procedure-related strokes, myocardial infarction (MI), and death.1,2 In addition, data analyzed from the Society for Vascular Surgery Vascular Quality Initiative TCAR Surveillance Project actually showed lower rates of postoperative MI and cranial nerve injury in patients undergoing TCAR compared with patients undergoing CEA.3
TCAR has also been associated with shorter procedure times and overall hospital stays, which offers another advantage compared with CEA.4 Additionally, use of regional anesthesia (RA) over general anesthesia (GA) in carotid surgery further shortens hospital stays and improves patient perception of recovery in appropriately chosen patients.5, 6, 7 Although there are few studies specifically analyzing anesthesia type in TCAR, the use of RA might be an important way to improve resource use for carotid surgeries.
Given the benefits in patient outcomes and resource use with TCAR, the advantages of TCAR become particularly relevant in the setting of the coronavirus disease 2019 pandemic. Hospital resource use is under constant review, especially given the extent of postoperative care needed for most vascular procedures. In this study, we sought to evaluate the feasibility of TCAR using RA and low-intensity postoperative care at our institution.
Methods
All patients at high risk for CEA undergoing TCAR at a single institution from 2018 to 2020 were reviewed. Consent for publication and institutional review board approval was obtained for all patients reviewed. Perioperative management was standardized by use of an institutional protocol including hemodynamic parameters (goal heart rate 60-100 bpm, goal mean arterial pressure >65mm Hg with systolic blood pressure<160mm Hg) and requisite medications (medication reconciliation performed on all patients), anticoagulation or antiplatelet regimens, neurovascular examination guidelines (neurovascular examination both preoperatively and postoperatively), and nursing instructions. Anesthetic modality was at the surgeon’s preference.
Patients were transferred to postanesthesia care unit (PACU) for 2hours (1:1/1:2 nursing ratio) followed by the step-down unit (1:4 nursing ratio), to PACU for 4hours followed by the floor (1:6 ratio) or alternatively transferred to intensive care unit (ICU) (1:1 ratio). Intravenous (IV) blood pressure medications could be administered at all environments except the floor. The step-down unit was the preferred location with regular floor used when step-down beds were unavailable and ICU beds were used only when higher levels of vasoactive medication or ventilatory support were required. Recovery location and length of stay were recorded.
Anesthetic choice was at surgeon discretion, with one provider favoring GA for all carotid procedures and two providers preferring regional block and selectively using GA for impaired neck mobility, patient inability to lay flat and still (ie, back pain, recent stroke, psychological impairment), or patient anxiety or request. RA consisted of a superficial cervical block performed by a dedicated RA team. The use of ultrasound guidance versus anatomic landmarks and lidocaine versus ropivacaine was at the anesthetists’ discretion.
Results
A total of 83 patients underwent TCAR during the study period. The mean age was 72± 9years, and 59% were male. Thirty-six percent of patients were symptomatic.
Anesthesia type
RA with ropivacaine or lidocaine was used for 84% of patients with none converted to GA intraoperatively. Thirteen patients were selected to undergo TCAR with GA in the preoperative evaluation. There were no significant differences between the medical comorbidities of patients chosen to undergo GA or RA.
Intraoperative interventions
Overall, the mean procedure time (time spent from incision to closure) was 75minutes with a mean flow reversal time of 8minutes. When accounting for anesthesia type, mean procedure time was significantly longer in patients undergoing TCAR with GA (Table). However, there was no significant difference in flow reversal time between RA and GA.
Table
Intraoperative times with regional anesthesia (RA) versus general anesthesia (GA)
| RA, minutes | GA, minutes | P value | |
|---|---|---|---|
| Mean procedure time | 72.0± 18.1 | 94.8± 37.1 | .049 |
| Mean flow reversal time | 7.9± 3.4 | 9.8± 8.9 | .454 |
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The most common intervention intraoperatively was for hypotension, with 78% of patients requiring vasopressors, most commonly IV phenylephrine. Patients under GA required significantly more phenylephrine than those under RA (4997.0± 3602.3μg vs 1736.5± 1826.9μg, respectively; P= .01). In addition, 39% of all patients required antihypertensives, and 10% required treatment for bradycardia.
Postoperative care
Postoperatively, only seven patients (8%) were monitored in an ICU overnight (decided perioperatively). In most cases, this was decided for symptomatic patients with prior neurological symptoms. However, one patient was admitted to the ICU for a postoperative neurological event and another patient owing to pulseless electrical activity arrest. The remaining 76 patients (92%) were monitored in PACU, of which 8 were transferred to the floor after 4hours, and 13 were discharged directly from PACU owing to limited bed availability (Fig1). Fifty-five of those in PACU were transferred to the step-down unit after 2hours and discharged from there.
Fig1
Postoperative location. ICU, intensive care unit; PACU, postanesthesia care unit.
The majority of patients were maintained at an appropriate blood pressure with oral antihypertensives. However, 14 patients required IV medications for hypertension or hypotension postoperatively. Of the 14, only 2 patients had undergone TCAR under GA. Six patients required IV treatment for hypertension with cardene, and eight patients required IV vasoactive support with phenylephrine. When compared with patients not requiring IV medications, patients treated with IV cardene or phenylephrine had longer hospital stays, although this did not reach significance (2.1± 2.9days vs 4.1± 4.7days, respectively; P= .162). Out of 13 total patients who underwent TCAR with GA, only 3 patients required ICU admission. There was no postoperative location difference by surgeon, only by anesthetic.
Length of hospital stay
The mean length of hospital stay for all patients was 2.4± 3.3days with a median length of hospital stay of 1day. The mean length of ICU stay was 3.7± 5.1days (range, 1-15days). Patients requiring ICU stay had a longer overall length of postoperative hospital stay compared with patients that did not require ICU care (Fig2) (5.4± 5.7days vs 1.5± 1.5days, respectively; P= .119). When accounting for differences in anesthesia type, the mean postoperative length of stay for patients undergoing TCAR with GA was also higher than those undergoing TCAR with RA (Fig2) (4.2± 4.9days vs 1.4± 1.2days, respectively; P= .066). Median length of stay for patients undergoing RA and GA were both 1day.
Fig2
Length of hospital stay by anesthesia type and intensive care unit (ICU) stay.
Postoperative complications
The incidence of stroke, death, and MI was 2.4% (2 patients). Both of these patients were treated under GA. There was one postoperative stroke considered to be a recrudescence of a prior stroke and one respiratory arrest fatality in a frail patient with a neck hematoma.
Discussion
In this study, we have shown that patients can be safely and effectively treated with TCAR while minimizing ICU stays and improving resource use through shorter procedure times. In our patient sample, opting to perform TCAR under RA over GA was associated with a shorter length of hospital stay and total procedure time, while minimizing postoperative complications. None of the patients undergoing TCAR under RA experienced stroke, MI, or death in the immediate postoperative period, whereas 2 of the 14 patients undergoing TCAR with GA experienced postoperative complications. Importantly, there was no significant difference in the presence of medical comorbidities between the two groups, although our analysis does not account for differences in the severity of disease.
The optimal mode of anesthetic delivery in carotid surgery has been debated for years and to this date, there has been no clear consensus between the use of GA versus RA. Although both options have advantages and disadvantages, our institution prefers the use of RA, to promptly diagnose any neurological changes in the patient intraoperatively. The most well-known of studies comparing RA vs GA, the GA versus RA for carotid surgery (GALA) trial showed no statistically significant differences in patient outcome between RA and GA.8 Several smaller studies have also shown that RA in CEA allows for a shorter surgical time and ICU and hospital stays with equal or better patient outcomes in stroke rate, MI, and death when compared with GA.5,9,10 Although few studies have been done comparing GA with RA after TCAR, the existing studies conclude that patients receiving RA had significantly shorter hospital stays and a lower 30-day mortality rate, consistent with what we report here.11 As we have demonstrated here, a majority of patients can be safely treated with RA, and thus we recommend regional block anesthetic as principal choice unless patients exhibit impaired neck mobility, patient inability to lay flat and still (ie, back pain, recent stroke, psychological impairment), or severe anxiety.
Treatment with IV medications for hypertension or hypotension postoperatively was also associated with longer hospital stays. These findings are also supported by another single-center, retrospective review showing that hemodynamic instability in the immediate postoperative period after TCAR is associated with a longer time in the ICU, as well as overall a longer length of hospital stay.12 In a larger Vascular Quality Initiative study, postoperative hypotension requiring vasoactive support for longer than 15minutes was associated with longer hospital stays and higher rates of neurologic and cardiac events.13 Several risk factors for development of postoperative hemodynamic instability have been identified, including symptomatic carotid artery stenosis, preoperative hypertension, and calcified plaques.14
Several limitations to our research exist, including a smaller sample size of patients undergoing TCAR with GA compared with RA, which may contribute to some of the nonsignificant findings. In addition, one of the patients undergoing TCAR with GA required ICU admission for 15days, which likely contributed to the prolonged mean length of stay in GA patients versus RA patients. Our analysis with the median length of stay is, therefore, more appropriate in this case, with median length of stay showing no significant difference between GA and RA patients.
Conclusions
Using perioperative care protocols, TCAR can safely be performed while avoiding both GA and an ICU stay in most patients. Opting for RA over GA may decrease the length of hospital stay and procedure times, while maintaining equal or better patient outcomes.
Author Contributions
Conception and design: VM, PT, CC, AD, MW
Analysis and interpretation: VM, PT, CC, AD, MW
Data collection: VM, PT, CC, AD, MW
Writing the article: VM, MW
Critical revision of the article: VM, PT, CC, AD, MW
Final approval of the article: VM, PT, CC, AD, MW
Statistical analysis: VM, PT, CC, AD, MW
Obtained funding: Not applicable
Overall responsibility: MW
Notes
From the Society for Vascular Surgery
Footnotes
Author conflict of interest: none.
The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.
References
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