Asian Cardiovasc Thorac Ann 2008;16:327-328
© 2008 Asia Publishing EXchange Ltd
Simultaneous Bilateral Carotid Endarterectomy Under Local Anesthesia
Athanassios Portinos, MD,
Emmanuel Kefaloyannis, MD,
George Philippakis, MD,
Apostolos Dountsis, MD,
Charalambos Zisis, MD,
Ion Bellenis, MD
Department of Thoracic & Vascular Surgery, Evagelismos General Hospital, Athens, Greece
For reprint information contact: Athanassios Portinos, MD, Tel: 30 210 720 1506, Fax: 30 210 722 4449, Email: sportinos{at}hotmail.com, Department of Thoracic & Vascular Surgery, Evagelismos General Hospital, 45–47 Ipsilantou, 10676, Athens, Greece.
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ABSTRACT
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A 75-year-old man with bilateral carotid stenosis and severe coronary artery disease underwent successful simultaneous bilateral carotid endarterectomy under local anesthesia. A few days later, coronary artery bypass grafting was performed with no complications.
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INTRODUCTION
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Carotid endarterectomy (CEA) under local anesthesia seems to have gained ground in the vascular community, mainly due to optimal neurologic control during the procedure. Simultaneous bilateral carotid endarterectomy under local anesthesia is described in a patient who had to undergo another major operation. Experience of 212 consecutive CEA procedures (unilateral or staged bilateral) under local anesthesia in the last 4 years helped us in the decision-making.
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CASE REPORT
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A 75-year-old man was admitted for urgent coronary artery bypass grafting (CABG) due to unstable angina (3-vessel disease). He had suffered a left-sided ischemic stroke 2 months earlier, with associated slight weakness of the right upper and lower limbs. A Duplex scan revealed > 80% stenosis of the symptomatic left internal carotid artery, > 90% stenosis of the right internal carotid artery, and occlusion of the right vertebral artery. Arteriography (Figure 1
) confirmed these findings and demonstrated a complete circle of Willis. It was decided to perform simultaneous bilateral CEA under local anesthesia before CABG, as the safest surgical strategy. During CEA, the patient was under anesthesiological control and continuous monitoring by electrocardiogram, invasive arterial blood pressure measurement, pulse rate, and oxygen saturation. Neurologic control was achieved by the patient squeezing a toy in the contralateral hand, and by verbal communication. Both sides of the neck were scrubbed and draped. After superficial local anesthesia (lidocaine 1%) of the symptomatic left side, we proceeded with the usual steps: dissection of the left carotids, general heparinization, 3-min cross clamp test of the left carotids (which was negative for neurologic deficiency), followed by left internal CEA and closure of the arteriotomy. Then the head was turned to the other side and the same steps were followed for the right side (cross clamp test was negative). Finally, both skin incisions were closed (Figure 2). No patch or shunt was used. Systolic arterial blood pressure ranged from 110 to 170 mm Hg, and pulse rate from 55 to 110 beats·min–1. No neurologic deficiency appeared during the procedure. There was no evidence of cardiac or respiratory dysfunction (oxygen saturation 
93%). The cross clamp times were 15 min for the left side and 13 min for the right side. The operative duration was 2 hours 15 min, the patient cooperated very well, and no sedatives were used. He remained under close monitoring for 24 hours, without any remarkable instability in blood pressure, pulse rate, respiratory or cardiac function. No clinical evidence of hyperfusion syndrome or cranial nerve injury was noticed. On the 4th postoperative day, he underwent successful CABG, and was discharged from the hospital 8 days later. One month later, neurologic examination revealed no further neurologic deficiency.
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Figure 1. Arteriography showing severe bilateral carotid stenosis and occlusion of the right vertebral artery.
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Figure 2. Simultaneous bilateral carotid endarterectomy under local anesthesia, just before the skin closure.
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DISCUSSION
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Although in severe bilateral carotid lesions, most surgeons prefer a staged procedure, Sato and colleagues1 found symptoms of transient ischemic attack in the nonoperated side between stages in up to 38%. Other advantages of simultaneous bilateral CEA over a staged procedure are avoidance of the risks from repeat anesthesia and surgical procedures, and reduced psychological stress.2 Studies comparing local with general anesthesia in CEA have provided evidence of the benefits of local anesthesia: lower incidence of shunt, greater safety in the elderly, less perioperative hemodynamic instability, thorough assessment of neurologic function, fewer cardiac and pulmonary complications, and appropriateness in ischemic cardiac disease.3–8
In our case, although the cerebral insufficiency could be judged as serious, the patient did not display symptoms of hyperfusion syndrome. Local anesthesia may decrease the risk of hyperfusion syndrome by reducing both systolic and diastolic pressures and their fluctuations.5 After the successful simultaneous CEA under local anesthesia, cardiac surgeons proceeded with the best neurologic safety to perform CABG. An alternative method in our case would have been unilateral CEA and later contralateral CEA combined with CABG. Potential disadvantages are an increased stroke risk after CEA secondary to protamine use during CABG, and a delay of full recognition of a postoperative stroke until after the completion of CABG.
To date, there are no precise guidelines on which strategy is best for cases of both carotid and coronary disease, and the indications for carotid revascularization before CABG are controversial. Another strategy could be revascularization of the symptomatic lesion first, which is usually the unstable angina prompting CABG. However, this may lead to a higher rate of postoperative stroke. Simultaneous bilateral CEA under local anesthesia may be preferable for many patients with operable bilateral carotid stenosis, especially those who have to undergo another major operation such as CABG. This case may help to clarify future strategies and might form the basis of a prospective study on CEA plus CABG in the same admission.
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REFERENCES
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ABSTRACT
INTRODUCTION
