Vascular surgical patients are a diverse group of patients who tend to be elderly, with multiple comorbidities, while vascular procedures may involve significant blood loss and ischemia of tissues beyond the arterial obstruction. Regional anesthesia techniques may offer benefits to patients undergoing vascular surgery because of their cardiorespiratory comorbidities. However, this group of patients is commonly receiving multiple medications, including anticoagulants, so regional techniques are not without risks. This review will discuss this topic based around 3 fundamental revascularization procedures, carotid, abdominal aortic aneurysm repair, and infrainguinal surgery, discussing the clinical applications of regional techniques relevant to each key area.
VandermeulenE. Regional anaesthesia and anticoagulation. Best Pract Res Clin Anaesthesiol. 2010;24:121-131.
2.
WalshSRBhuttaHTangTY. Anaesthetic specialisation leads to improved early- and medium-term survival following major vascular surgery. Eur J Vasc Endovasc Surg. 2010;39:719-725.
3.
HoltPJPolonieckiJDLoftusIMThompsonMM. Meta-analysis and systematic review of the relationship between hospital volume and outcome following carotid endarterectomy. Eur J Vasc Endovasc Surg. 2007;33:645-651.
4.
HoltPJPolonieckiJDLoftusIMMichaelsJAThompsonMM. Epidemiological study of the relationship between volume and outcome after abdominal aortic aneurysm surgery in the UK from 2000 to 2005. Br J Surg. 2007;94:441-448.
5.
EastcottHHPickeringGWRobCG. Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia. Lancet. 1954;267:994-996.
6.
LewisSCWarlowCPBodenhamAR. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet. 2008;372:2132-2142.
7.
RothwellPMGutnikovSAWarlowCP; European Carotid Surgery Trialists Collaboration. Reanalysis of the final results of the European Carotid Surgery Trial. Stroke. 2003;34:514-523.
8.
North American Symptomatic Carotid Endarterectomy Trial Investigators. Clinical alert: benefit of carotid endarterectomy for patients with high-grade stenosis of the internal carotid artery. National Institute of Neurological Disorders and Stroke, Stroke and Trauma Division. Stroke. 1991;22:816-817.
9.
European Carotid Surgery Trialists Collaboration. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet. 1998;351:1379-1387.
10.
National Institute of Neurological Disorders and Stroke. Carotid endarterectomy for patients with asymptomatic internal carotid artery stenosis. J Neurol Sci. 1995;129:76-77.
11.
BondRRerkasemKRothwellPM. Systematic review of the risks of carotid endarterectomy in relation to the clinical indication for and timing of surgery. Stroke. 2003;34:2290-2301.
12.
RantnerBKolleritsBSchmidauerC. Carotid endarterectomy within seven days after the neurological index event is safe and effective in stroke prevention. Eur J Vasc Endovasc Surg. 2011;42:732-739.
HeadBPPatelP. Anesthetics and brain protection. Curr Opin Anaesthesiol. 2007;20:395-399.
15.
PictonPChambersJShanksADorjeP. The influence of inspired oxygen fraction and end-tidal carbon dioxide on post-cross-clamp cerebral oxygenation during carotid endarterectomy under general anesthesia. Anesth Analg. 2010;110:581-587.
16.
PennekampCWMollFLde BorstGJ. The potential benefits and the role of cerebral monitoring in carotid endarterectomy. Curr Opin Anaesthesiol. 2011;24:693-697.
17.
RerkasemKRothwellPM. Local versus general anaesthesia for carotid endarterectomy. Cochrane Database Syst Rev. 2008;(4):CD000126. doi:10.1002/14651858.CD000126.pub3.
18.
GuayJ. The GALA trial: answers it gives, answers it does not. Lancet. 2008;372:2092-2093.
WijeyaratneSMCollinsMABarthJHGoughMJ. Jugular venous neurone specific enolase (NSE) increases following carotid endarterectomy under general, but not local, anaesthesia. Eur J Vasc Endovasc Surg. 2009;38:262-266.
21.
HudorovicNLovricevicIHajnicHAhelZ. Postoperative internal carotid artery restenosis after local anesthesia: presence of risk factors versus intraoperative shunt. Interact Cardiovasc Thorac Surg. 2010;11:182-184.
22.
Mazul-SunkoBHromatkoITadinacM. Subclinical neurocognitive dysfunction after carotid endarterectomy-the impact of shunting. J Neurosurg Anesthesiol. 2010;22:195-201.
23.
UmbrainVKeerisJD’HaeseJ. Isoflurane, desflurane and sevoflurane for carotid endarterectomy. Anaesthesia. 2000;55:1052-1057.
24.
SmithJSRoizenMFCahalanMK. Does anesthetic technique make a difference? Augmentation of systolic blood pressure during carotid endarterectomy: effects of phenylephrine versus light anesthesia and of isoflurane versus halothane on the incidence of myocardial ischemia. Anesthesiology. 1988;69:846-853.
25.
StonehamMDWarnerO. Blood pressure manipulation during awake carotid surgery to reverse neurological deficit after carotid cross-clamping. Br J Anaesth. 2001;87:641-644.
26.
StonehamMDMartinT. Increased oxygen administration during awake carotid surgery can reverse neurological deficit following carotid cross-clamping. Br J Anaesth. 2005;94:582-585.
DaviesMJSilbertBSScottDACookRJMooneyPHBlythC. Superficial and deep cervical plexus block for carotid artery surgery: a prospective study of 1000 blocks. Reg Anesth. 1997;22:442-446.
32.
RamachandranSKPictonPShanksADorjePPanditJJ. Comparison of intermediate vs subcutaneous cervical plexus block for carotid endarterectomy. Br J Anaesth. 2011;107:157-163.
33.
StonehamMDDoyleARKnightonJDDorjePStanleyJC. Prospective, randomized comparison of deep or superficial cervical plexus block for carotid endarterectomy surgery. Anesthesiology. 1998;89:907-912.
34.
ChoquetODadureCCapdevilaX. Ultrasound-guided deep or intermediate cervical plexus block: the target should be the posterior cervical space. Anesth Analg. 2010;111:1563-1565.
EinavSLandesbergGPrudDAnnerHBerlatzkyY. A case of nerves. Regional Anesthesia. 1996;21:168-170.
37.
BarringerCWilliamsJMMcCrirrickAEarnshawJJ. Regional anaesthesia and propofol sedation for carotid endarterectomy. ANZ J Surg. 2005;75:546-549.
38.
CoppiGMorattoRRagazziG. Effectiveness and safety of carotid endarterectomy under remifentanil. J Cardiovasc Surg (Torino). 2005;46:431-436.
39.
McCutcheonCAOrmeRMScottDADaviesMJMcGladeDP. A comparison of dexmedetomidine versus conventional therapy for sedation and hemodynamic control during carotid endarterectomy performed under regional anesthesia. Anesth Analg. 2006;102:668-675.
40.
LeoniAMagrinSMascottoG. Cervical plexus anesthesia for carotid endarterectomy: comparison of ropivacaine and mepivacaine. Can J Anaesth. 2000;47:185-187.
41.
CristalliAArlatiSBettinelliLBracconaroGMarconiGZerbiS. Regional anesthesia for carotid endarterectomy: a comparison between ropivacaine and levobupivacaine. Minerva Anestesiol. 2009;75:231-237.
42.
DawsonARDysartRHAmerenaJV. Arterial lignocaine concentrations following cervical plexus blockade for carotid endarterectomy. Anaesth Intensive Care. 1991;19:197-200.
43.
PöppingDMEliaNMarretEWenkMTramèrMR. Clonidine as an adjuvant to local anesthetics for peripheral nerve and plexus blocks: a meta-analysis of randomized trials. Anesthesiology. 2009;111:406-415.
44.
SindjelicRPVlajkovicGPDavidovicLBMarkovicDZMarkovicMD. The addition of fentanyl to local anesthetics affects the quality and duration of cervical plexus block: a randomized, controlled trial. Anesth Analg. 2010;111:234-237.
45.
PanditJJSatya-KrishnaRGrationP. Superficial or deep cervical plexus block for carotid endarterectomy: a systematic review of complications. Br J Anaesth. 2007;99:159-169.
46.
López del CastilloADelgado ArnáizCGarcía del ValleS. Full facial paralysis after a superficial cervical plexus block [in Spanish]. Rev Esp Anestesiol Reanim. 2004;51:171-173.
47.
BecqueminJPPilletJCLescalieF. A randomized controlled trial of endovascular aneurysm repair versus open surgery for abdominal aortic aneurysms in low- to moderate-risk patients. J Vasc Surg. 2011;53:1167-1173.e1.
48.
EVAR Trial Participants. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR Trial 1): randomised controlled trial. Lancet. 2005;365:2179-2186.
49.
EVAR Trial Participants. Endovascular aneurysm repair and outcome in patients unfit for open repair of abdominal aortic aneurysm (EVAR Trial 2): randomised controlled trial. Lancet. 2005;365:2187-2192.
50.
ButhJHarrisPLvan MarrewijkCFransenG. The significance and management of different types of endoleaks. Semin Vasc Surg. 2003;16:95-102.
BettexDALachatMPfammatterTSchmidlinDTurinaMISchmidER. To compare general, epidural and local anaesthesia for endovascular aneurysm repair (EVAR). Eur J Vasc Endovasc Surg. 2001;21:179-184.
53.
RuppertVLeursLJSteckmeierBButhJUmscheidT. Influence of anesthesia type on outcome after endovascular aortic aneurysm repair: an analysis based on EUROSTAR data. J Vasc Surg. 2006;44:16-21.
54.
VerhoevenELCinaCSTielliuIF. Local anesthesia for endovascular abdominal aortic aneurysm repair. J Vasc Surg. 2005;42:402-409.
55.
EdwardsMSAndrewsJSEdwardsAF. Results of endovascular aortic aneurysm repair with general, regional, and local/monitored anesthesia care in the American College of Surgeons National Surgical Quality Improvement Program database. J Vasc Surg. 2011;54:1273-1282.
56.
FloresJANishibeTKoyamaM. Combined spinal and epidural anesthesia for abdominal aortic aneurysm surgery in patients with severe chronic pulmonary obstructive disease. Int Angiol. 2002;21:218-221.
57.
BerardiGFerreroEFaddeM. Combined spinal and epidural anesthesia for open abdominal aortic aneurysm surgery in vigil patients with severe chronic obstructive pulmonary disease ineligible for endovascular aneurysm repair. Analysis of results and description of the technique. Int Angiol. 2010;29:278-283.
58.
ParkWYThompsonJSLeeKK. Effect of epidural anesthesia and analgesia on perioperative outcome: a randomized, controlled Veterans Affairs cooperative study. Ann Surg. 2001;234:560-571.
59.
MoracaRJSheldonDGThirlbyRC. The role of epidural anesthesia and analgesia in surgical practice. Ann Surg. 2003;238:663-673.
60.
RiggJRJamrozikKMylesPS. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet. 2002;359:1276-1282.
61.
GuayJ. The benefits of adding epidural analgesia to general anesthesia: a metaanalysis. J Anesth. 2006;20:335-340.
62.
FratacciMDKimballWRWainJCKacmarekRMPolanerDMZapolWM. Diaphragmatic shortening after thoracic surgery in humans. Effects of mechanical ventilation and thoracic epidural anesthesia. Anesthesiology. 1993;79:654-665.
63.
ReederMKMuirADFoexPGoldmanMDLohLSmartD. Postoperative myocardial ischaemia: temporal association with nocturnal hypoxaemia. Br J Anaesth. 1991;67:626-631.
64.
RosenbergJRasmussenVvon JessenFUllstadTKehletH. Late postoperative episodic and constant hypoxaemia and associated ECG abnormalities. Br J Anaesth. 1990;65:684-691.
65.
BallantyneJCCarrDBdeFerrantiS. The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials. Anesth Analg. 1998;86:598-612.
66.
WaurickRVan AkenH. Update in thoracic epidural anaesthesia. Best Pract Res Clin Anaesthesiol. 2005;19:201-213.
67.
KehletHHolteK. Effect of postoperative analgesia on surgical outcome. Br J Anaesth. 2001;87:62-72.
68.
CookTMCounsellDWildsmithJA; Royal College of Anaesthetists Third National Audit Project. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth. 2009;102:179-190.
69.
CharltonSCynaAMMiddletonPGriffithsJD. Perioperative transversus abdominis plane (TAP) blocks for analgesia after abdominal surgery. Cochrane Database Syst Rev. 2010;(12):CD007705. doi:10.1002/14651858.CD007705.pub2.
70.
SiddiquiMRSajidMSUnclesDRCheekLBaigMK. A meta-analysis on the clinical effectiveness of transversus abdominis plane block. J Clin Anesth. 2011;23:7-14.
71.
NirajGKelkarAJeyapalanI. Comparison of analgesic efficacy of subcostal transversus abdominis plane blocks with epidural analgesia following upper abdominal surgery. Anaesthesia. 2011;66:465-471.
CornishPDeaconA. Rectus sheath catheters for continuous analgesia after upper abdominal surgery. ANZ J Surg. 2007;77:84.
74.
OsakaYKashiwagiMNagatsukaYOosakuMHiroseC. Ultrasound-guided rectus sheath block for upper abdominal surgery [in Japanese]. Masui. 2010;59:1039-1041.
75.
WadaMKitayamaMHashimotoH. Brief reports: plasma ropivacaine concentrations after ultrasound-guided rectus sheath block in patients undergoing lower abdominal surgery. Anesth Analg. 2012;114:230-232.
76.
NorgrenLHiattWRDormandyJA. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.
77.
BradburyAWAdamDJBellJ. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: an intention-to-treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplasty-first revascularization strategy. J Vasc Surg. 2010;51(5 suppl):5S-17S.
SimonMJVeeringBTStienstraRvan KleefJWBurmAG. The effects of age on neural blockade and hemodynamic changes after epidural anesthesia with ropivacaine. Anesth Analg. 2002;94:1325-1330.
80.
CookPTDaviesMJCroninKDMoranP. A prospective randomised trial comparing spinal anaesthesia using hyperbaric cinchocaine with general anaesthesia for lower limb vascular surgery. Anaesth Intensive Care. 1986;14:373-380.
81.
DamaskMCWeissmanCToddG. General versus epidural anesthesia for femoral-popliteal bypass surgery. J Clin Anesth. 1990;2:71-75.
82.
ChristophersonRBeattieCFrankSM. Perioperative morbidity in patients randomized to epidural or general anesthesia for lower extremity vascular surgery. Perioperative Ischemia Randomized Anesthesia Trial Study Group. Anesthesiology. 1993;79:422-434.
83.
RosenfeldBABeattieCChristophersonR. The effects of different anesthetic regimens on fibrinolysis and the development of postoperative arterial thrombosis. Perioperative Ischemia Randomized Anesthesia Trial Study Group. Anesthesiology. 1993;79:435-443.
84.
TumanKJMcCarthyRJMarchRJDeLariaGAPatelRVIvankovichAD. Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery. Anesth Analg. 1991;73:696-704.
85.
HaljamáeH. Effects of anesthesia on leg blood flow in vascular surgical patients. Acta Chir Scand Suppl. 1989;550:81-87.
86.
BodeRHLewisKPZarichSW. Cardiac outcome after peripheral vascular surgery. Comparison of general and regional anesthesia. Anesthesiology. 1996;84:3-13.
87.
DoddsTFillingerMWalshDSurgenorSMandelDYeagerM. Clinical outcomes after lower extremity revascularization: a comparison of epidural and general anesthesia. J Appl Res. 2007;7:238-249.
SinghNSidawyANDezeeK. The effects of the type of anesthesia on outcomes of lower extremity infrainguinal bypass. J Vasc Surg. 2006;44:964-970.
90.
YazigiAMadi-GebaraSHaddadFHayeckGTabetG. Intraoperative myocardial ischemia in peripheral vascular surgery: general anesthesia vs combined sciatic and femoral nerve blocks. J Clin Anesth. 2005;17:499-503.
91.
YazigiAMadi-GebaraSHaddadFHayeckGTabetG. Combined sciatic and femoral nerve blocks for infrainguinal arterial bypass surgery: a case series. J Cardiothorac Vasc Anesth. 2005;19:220-221.
92.
MackayCARazikWSimmsMH. Local anaesthetic for lower-limb revascularization in high-risk patients. Br J Surg. 1997;84:1096-1098.
93.
Basagan-MogolETurkerGYilmazMGorenS. Combination of a psoas compartment, sciatic nerve, and T12-L1 paravertebral blocks for femoropopliteal bypass surgery in a high-risk patient. J Cardiothorac Vasc Anesth. 2008;22:337-339.
94.
BarkmeierLDHoodDBSumnerDS. Local anesthesia for infrainguinal arterial reconstruction. Am J Surg. 1997;174:202-204.
