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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 3, May/June 2021
AFRICA
131
surgery was performed. One of the two patients with LMCA
lesions could not be saved and died. The other three patients
underwent successful CABG operations and were discharged
from the hospital.
Discussion
CEA has been shown to reduce the risk of stroke in both
asymptomatic and symptomatic patients in several large
trials.
3,4,9,10
Current European Society for Vascular Surgery
guidelines identify five different indications in patients with
carotid artery disease, including neurological symptomatology,
degree of carotid stenosis, medical co-morbidities, vascular
and local anatomical features and carotid plaque morphology.
The last three of these criteria were proposed as a means
of differentiating between CEA and carotid artery stenting
(CAS).
11
However, in terms of stroke and death, numerous
randomised trials did not find any significant difference between
CEA and CAS. Stenting may have some possible advantages,
such as avoidance of GA and surgical trauma,
12-14
although it
has also been identified as an independent predictor of retinal
embolisation.
15
In the 1960s, with the initiation of operations under LA,
many surgeons began to prefer it when performing operations.
16
In our clinic, many of the surgeons also prefer LA, resulting
in more CEA operations being performed under LA. Previous
studies have suggested that use of LA for CEA surgery may
change the attitude of many surgeons to the procedure.
17,18
Since
it alerts the surgeon for the necessity of a shunt, awake testing
of brain function during carotid clamping under LA is more
reliable than various indirect techniques that are used under
GA. Such an approach may be safer than operations performed
under GA, as evidenced by the lower number of shunts used in
these procedures. In our study, shunts were used less frequently
in patients who underwent CEA under CB anaesthesia; however,
this difference was not statistically significant.
Awake testing and cerebral monitoring are regarded as the
gold standard for shunting.
19
Although shunts should protect
the brain from strokes caused by low cerebral blood flow during
carotid clamping, they can damage the arterial wall, causing
embolisms in the brain.
LAmay have some advantages in terms of MI and pulmonary
complication rates, when compared with GA.
17
Furthermore,
LA is associated with a better assessment of neurological
outcomes.
20,21
The GALA study included 3 526 patients and
compared GA versus LA for carotid artery surgery. It found no
significant differences in quality of life, length of hospital stay,
or primary outcome (stroke, MI, death between randomisation
and 30 days after surgery) in the pre-specified subgroups of
age (above or below 75 years) or for those considered at higher
risk for surgery. While the study provided important insights
into disease outcomes based on treatment modalities, it did
not answer questions regarding the safety of CEA under LA in
patients at high risk for cardiovascular complications.
Conclusion
In our study, the postoperative MI rate was higher in the
CB-GA group, with four cases of postoperative MI in the
CB-GA group compared to none in the GA group. Based on
these observations, for patients requiring CEA and CABG,
performing both operations under GA and in the same session
was the safer option compared to initially performing CEA
under CB anaesthesia followed by CABG under GA.
References
1.
Eastcott HHG, Pickering GW, Robb CG. Reconstruction of internal
carotid artery in a patient with intermittent attacks of hemiplegia.
Lancet
1954;
2
: 994–996.
2.
DeBakey ME. Successful carotid endarterectomy for cerebrovascular
insufficiency. Nineteen-year follow-up.
J Am Med Assoc
1975:
233
;
Table 1. Demographic characteristics and
clinical variables of the patient population
Variables
GA group
(
n
= 18)
CB-GA group
(
n
= 16)
p
-value
Age
66.39 ± 8.64
67.44 ± 6.34
0.692
Male
14 (77.8)
12 (75.0)
0.999
Asymptomatic
15 (83.3)
13 (81.2)
0.999
Amaurosis fugax
–
–
–
TIA
3 (16.7)
2 (12.5)
0.999
Non-disabling stroke
–
–
–
Stroke
0 (0.0)
1 (6.2)
0.471
Smoking
9 (50.0)
7 (43.8)
0.716
HT
2 (11.1)
7 (43.8)
0.052
DM
2 (11.1)
4 (25.0)
0.387
Hypercholesterolaemia
1 (5.6)
2 (12.5)
0.591
CAD
13 (72.2)
11 (68.8)
0.999
PAD
0 (0.0)
2 (12.5)
0.214
Renal dysfunction
4 (22.2)
2 (12.5)
0.660
Obesity
2 (11.1)
2 (12.5)
0.999
GA: general anaesthesia; CB: cervical block; TIA: transient ischaemic attack;
HT: hypertension; DM: diabetes mellitus; CAD: coronary artery disease; PAD:
peripheral arterial disease.
Table 2. Intra-operative data of the patient groups
Variables
GA group
(n = 18)
CB-GA group
(n = 16)
p
-value
Clamping time
31.06 ± 3.57
41.25 ± 7.39 < 0.001
Contralateral obstruction
2 (11.1)
3 (18.8)
0.648
Shunt
2 (11.1)
3 (18.8)
0.648
Primer closure
6 (33.3)
4 (25.0)
0.715
Saphenous
0 (0.0)
1 (6.2)
0.471
PTFE
–
–
–
Dacron
12 (66.7)
11 (68.8)
0.897
GA: general anaesthetic; CB: central block; PTFE: polytetrafluoroethylene.
Table 3. Comparison of postoperative
complications between patient groups
Complications
GA group
(
n
= 18)
CB-GA group
(
n
= 16)
p-value
Bleeding
4 (22.2)
0 (0.0)
0.105
Infection
–
–
–
Cranial nerve damage
1 (5.6)
0 (0.0)
0.999
Early restenosis
–
–
–
Late restenosis
–
–
–
TIA
–
–
–
Stroke
–
–
–
Postoperative MI
0 (0.0)
4 (25.0)
0.039
Death
0 (0.0)
1 (6.2)
0.471
GA: general anaesthetic; CB: central block; TIA: transient ischaemic attack,
MI: myocardial infarction.