Con: General Anesthesia and Regional Anesthesia Are Equally Acceptable Choices for Carotid Endarterectomy

W rHEN considering the best approach to a clinica] problem or situation, clinicians must first consider the medical/ physiologic implications, and then the financial impact of that practice. After carefully reviewing the scholarly and seemingly eternal debate 1,2 about regional versus general anesthesia for carotid endarterectomy (CEA), it is the authors' conclusion that it just doesn't matter! First, the scientific and anecdotal evidence that exists to support the claim that either general or regional anesthesia may be used safely for CEA will be explored. Certainly, many recent studies 3-6 support the efficacy and benefit of CEA compared with medical management, and, therefore, this surgery will be performed more and more frequently. Cost issues associated with the surgery will be of increasing concern, and if one anesthetic provided a significant advantage over another, this would be important information to incorporate in practice. However, it will he shown that anesthetic costs are a small fraction of total hospitalization costs for CEA, and that early discharge is an easily achievable goal for most patients, regardless of the choice of anesthetic. There has never been a randomized, controlled trial involving enough patients that could convincingly determine the,, issue of whether one anesthetic is better than another for CEA. Complication rates for most reputable centers (both surgical and anesthetic) are relatively low, and, therefore, a study with adequate power to prove a significant difference attributable to anesthetic technique would require a huge multicenter trial, and would yield relatively little benefit. The literature is rife with case reports and nonrandomized trials purporting major economic and outcome improvements with regional anesthesia. 7-I° Similarly, other authors report satisfactory economic and outcome results with general anesthesia. 11,12 A recent review in the European literature found a paucity of well constructed and executed randomized controlled studies, and the overall number of patients studied prospectively was too few to support the extremely optimistic view held in the case reports by advocates of regional anesthesia.13 Neither technique is devoid of complications, and there are different challenges with each type of anesthetic. Both share the well-known risks of perioperafive cardiac and central nervous system morbidity (stroke or transient neurologic defick) associated with CEA. Conclusive evidence that one technique offers advantages regarding morbidity does not exist. One study did control for medical comorbidities of patients, and found no difference in major cardiac morbidity attributable to anesthetic technique between patients in the regional and general groups. 14 The predominant clinical challenges associated with general anesthesia concern adequacy of cerebral monitoring, and the usual issues of managing the hemodynamic changes of intubation and extubation. Many approaches for managing acute changes in hemodynamics exist, and at least one that works well should be part of any anesthesiologist's armamentarium. With regional anesthesia, cervical plexus blockade cm-ries the rare but devastating risks of intravascular injection, with ensuing seizures or unconsciousness in a patient with comproraised cerebrovascular reserve, and spinal or epidural injection is also possible. Intraoperatively, the patients may become confused or obtunded around the time of clamping, and may require the emergent induction of general anesthesia with an open neck wound. Regional anesthetics are not suitable for all cases, such as claustrophobic patients, patients with severe cough, extreme anxiety, and difficult airways. It is not always possible to determine these characteristics in advance of the operation 100% of the time. In teaching hospitals where surgical residents must develop expertise, cases often last longer than might be the norm in private practice, and a patient might find it difficult to remain still for an extended period of time. The surgeons in this institution find the technical aspects of the cases easier with the patients under general anesthesia, in part because of less movement from swallowing, and easier retraction and exposure, particularly with patients with high carotid bifurcations. Anatomic complications of airway compromise, neck hematoma, and other mechanical problems are described in the literature for both types of anesthetic practice, s and do not seem to be affected by anesthetic technique. Many advocates of general anesthesia have advocated its ability to deliver CMRO2-sparing isoflurane, and precise management of oxygenation and ventilation. Whereas a decrease in cerebral metabolic rate and presumably some cerebral protection from general anesthesia was recently shown in one European studyy the overall benefit of this may be small given that most intraoperative neurologic events in CEA patients are embolic in nature. 16 One study involving transcranial Doppler monitoring found no difference in embolic events during CEA between the regional and general anesthesia groups. 17 With the exception of patients having crescendo transient ischemic attacks, who require preoperative anticoagulation, or those patients recently recovered from stroke, the vast majority of patients at this institution have outpatient arteriograrns or ultrasound examinations, and less than 24-hour admissions for surgery. Like cardiac and neurologic morbidity, major financial morbidity following CEA is independent of anesthetic technique. Anesthetic drugs and charges are similar with general anesthesia versus regional anesthesia, and constitute a very small portion of the overall cost of CEA. In fact, intraoperative anesthesia costs were found to represent only about 5% of the total hospital costs in one study, is Anesthetic professional fees are the same regardless of type of anesthetic, and drug costs are a very small portion of the costs of an anesthetic.