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Surgery on the carotid artery with cervical block anesthesia
Surgery
on the Carotid
Cervical
Artery
with
Block Anesthesia*
Technical
Considerations
W. GERALD RAINER, M.D., CHARLES B. MCCRORY, M.D., AND ERNEST M. FEILER, M.D. Denver, Colorado
From the Departments of Surgery Joseph Hospital, Denver, Colorado.
N of
UMEROUSSURGICALand anesthetic vers designed temporary
[l-5].
Because
we
the
(136)
block
have
have
been
bidity
and
simplified in fifty-two
at
convinced the
patient,
we
have
in
the
artery. mortality
superficial patients
report our experience
surgical
The
time
resultant
have
of
response utilized majority
procedures low mor-
attendant cervical
of
described
anesthesia
of 148 reconstructive
on the carotid
maneu-
safe period
been
of monitoring
conscious
cervical
the
occlusion
surgery
the dependability of
to prolong
carotid
reconstructive
border of the sternomastoid muscle. Ligation and division of the common $acial vein is almost invariably advantageous to exposure superiorly unless the carotid bifurcation is unusually low. The caudal extent of the hypoglossal nerve is variable and must be considered as dissection is carried above the bifurcation, After the administration of 1.5 mg. aqueous heparin/kg. of body weight, trial occlusion is carried out by cross-clamping the common and external carotid arteries for three to four minutes while careful attention is paid to patient’s cerebral status. In our experience, intolerance to occlusion becomes manifest within twenty to thirty seconds if the remaining extracranial circulation is unable to support adequate cerebral function. In case of trial occlusion intolerance, it is discontinued promptly and internal shunting carried out immediately after the artery is opened. If patients have tolerated trial occlusion of three to four minutes without adverse effects, temporary shunting has not been necessary during the definitive part of the procedure. Temporary shunts were used eighteen times in this series of cases. After arteriotomy closure, neutralization of heparin is carried out by administering protamine sulfate in an amount equivalent to the heparin given. General anesthesia was Anesthetic Considerations. used twelve times because of complete occlusion, completed stroke with coma, patient’s preference, or the need for other reconstructive surgery. Complete cervical block anesthesia (both deep and superficial) was used for eighty-four procedures, while superficial cervical plexus block only was used for fifty-two operations. Superficial cervical block anesthesia is obtained by injecting 10 cc. of a 1.5 per cent solution of lido-
and Anesthesia, St.
plexus
encouraged
with
a
block us
to
in detail
MATERIAL AND METHODS One hundred forty-eight operaClinical Il4aterial. tions on the cervical carotid artery were performed on 116 patients during a three year period. The age of patients ranged from thirty-eight to seventy-eight years; symptoms were of a transient, ischemic nature in 110 patients (six patients had completed strokes). Three vessel arteriography (retrograde right brachial artery catheterization and percutaneous left carotid puncture technics) was performed in all patients. Ninety-nine patients had occlusive lesions (sixty unilateral; thirty-nine bilateral) while seventeen patients were shown to have acute kinks of the internal carotid artery. Surgical Considerations. The common, external, and internal carotid arteries are exposed, isolated, and encircled through an incision along the anterior
* Presented at the Eighteenth Annual Meeting of the Southwestern Surgical Congress, Las Vegas, Nevada, April 18-21, 1966. Vol. 112. November 1966
703
Rainer,
McCrory,
and Feiler
FIG. 2. Photograph taken during performance of superficial cervical nerve block. Anterior and posterior borders of sternomastoid muscle are outlined. FIG. 1. Diagrammatic landmarks showing block of superficial cervical nerves as they cross over sternomastoid muscle. Caine* with 1:200,000 epinephrine along the posterior border of the sternomastoid muscle. (Fig. 1 and 2.) Incisional skin infiltration is not used and only occasionally is additional injection of a local anesthetic necessary at the superior angle of the incision. Two to three cc. of lidocaine (without epinephrine) is injected under the carotid sheath immediately upon exposure of the common carotid artery, and 1 to 2 cc. of lidocaine is also injected under the adventitia of the carotid bifurcation once it is exposed. Duration of anesthesia is approximately ninety minutes with this technic. Blood pressure during the procedure is monitored frequently to insure normotensive or slightly hypertensive levels, but vasopressor administration is rarely necessary. Throughout the procedure the patient is engaged in conversation by the anesthesiologist, either with orderly planned reverse counting or casual dialogue. If slowed verbal response, unclear speech, or any suggestion of mental confusion occurs, the surgeon is immediately notified and trial occlusion promptly discontinued or temporary shunting instituted if actual surgical reconstruction is under way. Rarely is additional anesthesia necessary but small doses of hypnotics or sedatives may be administered safely if undue apprehension or restlessness is a problem. COMMENTS Because cervical employed routinely,
block anesthesia is not one is apt to become un-
* Supplied as Xylocaine@, manufactured by Astra Pharmaceutical Products, Inc., Worcester, Massachusetts.
familiar with some of its technical vagaries. Certainly, neither surgeon, anesthesiologist, nor patient is faced with problems of apprehension and restlessness if general anesthesia is employed. However, with the unconscious patient, the physician relies somewhat heavily on the indirect indications of cerebral oxygenation or else he employs a temporary shunt arbitrarily. with increasing experience with cervical block anesthesia, patient cooperation has been excellent. Limiting the extent of block to $e superficial cervical nerves has eliminated the somewhat more complex deep cervical injections and avoided potential hazards such as inadvertant intradural injection, vagal nerve impairment (with consequent recurrent laryngeal nerve paresis), and intraarterial injection. Superficial block is simple, quick, more acceptable to the patient, &arsd quite adequate unless the surgery should be gredictably prolonged by unusual disease manifestations. Even the surgeon may be more relaxed by confidence in exact moment to moment knowledge of the status of the patient’s cerebral function. Two deaths (one in a comatose patient with a completed stroke operated upon in an attempt to increase survival and one caused by myocardial infraction) occured within twentyfour hours of surgery in this series. Both operations were performed with general hypercarbic anesthesia. Another death occurred due to cerebral infarction seventy-two hours postoperatively; general anesthesia with in-
Carotid
Artery
and Cervical
duced hypercarbia had been employed in this instance also, because of associated vertebral arterial stenosis. There have been no late deaths attributable to the surgical procedure or of a cerebrovascular nature. SUMMARY 1. Our experience with 136 operations on the carotid artery performed with cervical block anesthesia is described. 2. Details of superficial cervical plexus block used in fifty-two patients are presented along with its advantages and simplicity. 3. The use of cervical block anesthesia for surgery on the carotid artery has proved highly satisfactory in our hands and allows for more confident monitoring of cerebral status. Acknowledgment: We wish to acknowledge the help of Mr. Ken Scott in illustration and photography and Miss Jane Baenen in prep-
Vol. 112. November
1966
Block
Anesthesia
7(I.5
aration of the manuscript. REFERENCES 1. DEBAKEY, M. E., CRAWFORD, E. S., MORRIS, G. A., JR., and COOLEY, D. A. Surgical considcmtions of occlusive disease of the innominate, carotid, subclavian and vertebral artcries. z4zn. Surg., 154: 698, 1961. 2. WELLS, B. A., KEATS, A. S., and COOLEY, D. A. Increased tolerance to cerebral ischemia produced by general anesthesia during temporary carotid occlusion. Surgery, 54: 216, 1963. 3. NAJAFI, H., Kinked internal carotid artery. nrrh. Surg., 89: 134, 1964. 4. DEBAKEY, M. E., CRAWFORD, E. S., COOLEY, D. A., MORRIS, G. C., JR., GARRETT, H. E., and FIELDS, W. S. Cerebral arterial insufficiency: one to eleven years result following arterial reconstructive operation. Ann. Surg., 161: 921, 1965. 5. LYOXS, C. Progress report of the joint study of extracranial arterial occlusion. In : Cerebral Vascular Diseases, 4th Conference. Edited by Sickert, R. G. and Whisnant, J. P. n’ew York, 1965. Grune & Stratton, Inc.
on the Carotid
Cervical
Artery
with
Block Anesthesia*
Technical
Considerations
W. GERALD RAINER, M.D., CHARLES B. MCCRORY, M.D., AND ERNEST M. FEILER, M.D. Denver, Colorado
From the Departments of Surgery Joseph Hospital, Denver, Colorado.
N of
UMEROUSSURGICALand anesthetic vers designed temporary
[l-5].
Because
we
the
(136)
block
have
have
been
bidity
and
simplified in fifty-two
at
convinced the
patient,
we
have
in
the
artery. mortality
superficial patients
report our experience
surgical
The
time
resultant
have
of
response utilized majority
procedures low mor-
attendant cervical
of
described
anesthesia
of 148 reconstructive
on the carotid
maneu-
safe period
been
of monitoring
conscious
cervical
the
occlusion
surgery
the dependability of
to prolong
carotid
reconstructive
border of the sternomastoid muscle. Ligation and division of the common $acial vein is almost invariably advantageous to exposure superiorly unless the carotid bifurcation is unusually low. The caudal extent of the hypoglossal nerve is variable and must be considered as dissection is carried above the bifurcation, After the administration of 1.5 mg. aqueous heparin/kg. of body weight, trial occlusion is carried out by cross-clamping the common and external carotid arteries for three to four minutes while careful attention is paid to patient’s cerebral status. In our experience, intolerance to occlusion becomes manifest within twenty to thirty seconds if the remaining extracranial circulation is unable to support adequate cerebral function. In case of trial occlusion intolerance, it is discontinued promptly and internal shunting carried out immediately after the artery is opened. If patients have tolerated trial occlusion of three to four minutes without adverse effects, temporary shunting has not been necessary during the definitive part of the procedure. Temporary shunts were used eighteen times in this series of cases. After arteriotomy closure, neutralization of heparin is carried out by administering protamine sulfate in an amount equivalent to the heparin given. General anesthesia was Anesthetic Considerations. used twelve times because of complete occlusion, completed stroke with coma, patient’s preference, or the need for other reconstructive surgery. Complete cervical block anesthesia (both deep and superficial) was used for eighty-four procedures, while superficial cervical plexus block only was used for fifty-two operations. Superficial cervical block anesthesia is obtained by injecting 10 cc. of a 1.5 per cent solution of lido-
and Anesthesia, St.
plexus
encouraged
with
a
block us
to
in detail
MATERIAL AND METHODS One hundred forty-eight operaClinical Il4aterial. tions on the cervical carotid artery were performed on 116 patients during a three year period. The age of patients ranged from thirty-eight to seventy-eight years; symptoms were of a transient, ischemic nature in 110 patients (six patients had completed strokes). Three vessel arteriography (retrograde right brachial artery catheterization and percutaneous left carotid puncture technics) was performed in all patients. Ninety-nine patients had occlusive lesions (sixty unilateral; thirty-nine bilateral) while seventeen patients were shown to have acute kinks of the internal carotid artery. Surgical Considerations. The common, external, and internal carotid arteries are exposed, isolated, and encircled through an incision along the anterior
* Presented at the Eighteenth Annual Meeting of the Southwestern Surgical Congress, Las Vegas, Nevada, April 18-21, 1966. Vol. 112. November 1966
703
Rainer,
McCrory,
and Feiler
FIG. 2. Photograph taken during performance of superficial cervical nerve block. Anterior and posterior borders of sternomastoid muscle are outlined. FIG. 1. Diagrammatic landmarks showing block of superficial cervical nerves as they cross over sternomastoid muscle. Caine* with 1:200,000 epinephrine along the posterior border of the sternomastoid muscle. (Fig. 1 and 2.) Incisional skin infiltration is not used and only occasionally is additional injection of a local anesthetic necessary at the superior angle of the incision. Two to three cc. of lidocaine (without epinephrine) is injected under the carotid sheath immediately upon exposure of the common carotid artery, and 1 to 2 cc. of lidocaine is also injected under the adventitia of the carotid bifurcation once it is exposed. Duration of anesthesia is approximately ninety minutes with this technic. Blood pressure during the procedure is monitored frequently to insure normotensive or slightly hypertensive levels, but vasopressor administration is rarely necessary. Throughout the procedure the patient is engaged in conversation by the anesthesiologist, either with orderly planned reverse counting or casual dialogue. If slowed verbal response, unclear speech, or any suggestion of mental confusion occurs, the surgeon is immediately notified and trial occlusion promptly discontinued or temporary shunting instituted if actual surgical reconstruction is under way. Rarely is additional anesthesia necessary but small doses of hypnotics or sedatives may be administered safely if undue apprehension or restlessness is a problem. COMMENTS Because cervical employed routinely,
block anesthesia is not one is apt to become un-
* Supplied as Xylocaine@, manufactured by Astra Pharmaceutical Products, Inc., Worcester, Massachusetts.
familiar with some of its technical vagaries. Certainly, neither surgeon, anesthesiologist, nor patient is faced with problems of apprehension and restlessness if general anesthesia is employed. However, with the unconscious patient, the physician relies somewhat heavily on the indirect indications of cerebral oxygenation or else he employs a temporary shunt arbitrarily. with increasing experience with cervical block anesthesia, patient cooperation has been excellent. Limiting the extent of block to $e superficial cervical nerves has eliminated the somewhat more complex deep cervical injections and avoided potential hazards such as inadvertant intradural injection, vagal nerve impairment (with consequent recurrent laryngeal nerve paresis), and intraarterial injection. Superficial block is simple, quick, more acceptable to the patient, &arsd quite adequate unless the surgery should be gredictably prolonged by unusual disease manifestations. Even the surgeon may be more relaxed by confidence in exact moment to moment knowledge of the status of the patient’s cerebral function. Two deaths (one in a comatose patient with a completed stroke operated upon in an attempt to increase survival and one caused by myocardial infraction) occured within twentyfour hours of surgery in this series. Both operations were performed with general hypercarbic anesthesia. Another death occurred due to cerebral infarction seventy-two hours postoperatively; general anesthesia with in-
Carotid
Artery
and Cervical
duced hypercarbia had been employed in this instance also, because of associated vertebral arterial stenosis. There have been no late deaths attributable to the surgical procedure or of a cerebrovascular nature. SUMMARY 1. Our experience with 136 operations on the carotid artery performed with cervical block anesthesia is described. 2. Details of superficial cervical plexus block used in fifty-two patients are presented along with its advantages and simplicity. 3. The use of cervical block anesthesia for surgery on the carotid artery has proved highly satisfactory in our hands and allows for more confident monitoring of cerebral status. Acknowledgment: We wish to acknowledge the help of Mr. Ken Scott in illustration and photography and Miss Jane Baenen in prep-
Vol. 112. November
1966
Block
Anesthesia
7(I.5
aration of the manuscript. REFERENCES 1. DEBAKEY, M. E., CRAWFORD, E. S., MORRIS, G. A., JR., and COOLEY, D. A. Surgical considcmtions of occlusive disease of the innominate, carotid, subclavian and vertebral artcries. z4zn. Surg., 154: 698, 1961. 2. WELLS, B. A., KEATS, A. S., and COOLEY, D. A. Increased tolerance to cerebral ischemia produced by general anesthesia during temporary carotid occlusion. Surgery, 54: 216, 1963. 3. NAJAFI, H., Kinked internal carotid artery. nrrh. Surg., 89: 134, 1964. 4. DEBAKEY, M. E., CRAWFORD, E. S., COOLEY, D. A., MORRIS, G. C., JR., GARRETT, H. E., and FIELDS, W. S. Cerebral arterial insufficiency: one to eleven years result following arterial reconstructive operation. Ann. Surg., 161: 921, 1965. 5. LYOXS, C. Progress report of the joint study of extracranial arterial occlusion. In : Cerebral Vascular Diseases, 4th Conference. Edited by Sickert, R. G. and Whisnant, J. P. n’ew York, 1965. Grune & Stratton, Inc.