Marrocco-Trischitta Massimiliano M, Tiezzi Alessandro, Svampa Maria Gerarda, Bandiera Giovanni, Camilli Sante, Stillo Francesco, Petasecca Pierpaolo, Sampogna Francesca, Abeni Damiano, Guerrini Paolo
Department of Vascular Surgery, San Raffaele Hospital-IRCCS, Vita-Salute University, Viale Cassiodoro 12, 20145 Milan, Italy.
J Vasc Surg. 2004 Jun;39(6):1295-304. doi: 10.1016/j.jvs.2004.02.002.
Surgery for extracranial carotid artery disease has been challenged by carotid angioplasty stenting because the latter is less invasive and avoids surgical trauma. In fact, the magnitude of the perioperative stress response evoked by carotid endarterectomy (CEA) has never been evaluated. Our aim was to determine the degree of surgical trauma caused by CEA and to define differences related to the use of locoregional or general anesthesia.
We prospectively studied 113 consecutive CEAs performed on 109 patients admitted at a community institutional center. Patients were stratified for demographics and risk factors and operated on under locoregional (LA) or general anesthesia (GA) depending on both the surgeon preference and patient's compliance. Selective carotid shunting was performed for patients who manifested neurologic deficits under LA or had stump pressure values </=30 mm Hg under GA. Markers of the stress response, including cortisol, adrenocorticotropic hormone, prolactin, and C-reactive protein, were measured intraoperatively, before and after carotid artery cross-clamping (CACC), and postoperatively up to the third day after surgery. Hemodynamic variability was assessed during surgery and for 24 hours postoperatively. Operative times were also measured. Surgeons were considered as independent variables for stress response. Statistics were run by means of nonparametric tests and univariate and multivariate analysis with a linear regression model.
CEA was performed under GA in 63 cases (55.8%) and under LA in 50 (44.2%). The two groups were comparable in terms of demographics and risk factors. Intraoperatively, cortisol and adrenocorticotropic hormone levels were significantly higher in the LA group (both P <.001). CACC increased the intraoperative cortisol levels in both the GA (P =.019) and the LA groups (P =.006). However, in patients who underwent carotid shunting, this effect was abolished (GA group, P =.779; LA group, P = 1.0). During the early postoperative period there was no difference between the two groups. On postoperative day 1 the stress response was abolished in both groups. Prolactin levels increased intraoperatively in both the LA and GA groups and returned within preoperative values on postoperative day 1. Prolactin levels were higher in the GA group (P =.003 intraoperatively and P <.001 postoperatively). C-reactive protein significantly increased in both GA and LA groups on postoperative days 1 and 2 and started to decrease on day 3 with no differences between the two groups at any time. Hemodynamic variability and considered risk factors including individual surgeon were not significant variables. Gender-related differences were found only in prolactin secretion. The length of surgery had an impact for procedures that lasted >120 minutes. Three patients experienced an intraoperative neurologic event and had higher post-CACC cortisol values as compared to asymptomatic patients.
Intraoperative surgical stress was higher under LA and was blunted by carotid shunting under both LA and GA. Within 2 hours after surgery the anesthetic modality no longer had any impact on surgical trauma. The stress response to CEA, regardless of the type of anesthesia, was abolished within 24 hours. Intraoperative stress response, namely hypercortisolemia, directly correlated with subclinical and clinical cerebral hypoperfusion/ischemia during CACC. Hence, attenuation of the stress response to CEA might decrease the incidence of cerebral ischemic events.
颅外颈动脉疾病的手术治疗受到颈动脉血管成形术支架置入术的挑战，因为后者侵入性较小且避免了手术创伤。事实上，颈动脉内膜切除术（CEA）所引发的围手术期应激反应的程度从未得到评估。我们的目的是确定CEA造成的手术创伤程度，并明确与局部或全身麻醉使用相关的差异。
我们前瞻性地研究了在社区机构中心收治的109例患者所进行的113例连续CEA手术。根据人口统计学和危险因素对患者进行分层，并根据外科医生的偏好和患者的依从性，在局部麻醉（LA）或全身麻醉（GA）下进行手术。对在LA下出现神经功能缺损或在GA下残端压力值≤30 mmHg的患者进行选择性颈动脉分流。在术中、颈动脉交叉钳夹（CACC）前后以及术后直至术后第三天，测量应激反应标志物，包括皮质醇、促肾上腺皮质激素、催乳素和C反应蛋白。在手术期间和术后24小时评估血流动力学变异性。还测量了手术时间。外科医生被视为应激反应的独立变量。通过非参数检验以及线性回归模型的单变量和多变量分析进行统计。
63例（55.8%）患者在GA下进行CEA，50例（44.2%）在LA下进行。两组在人口统计学和危险因素方面具有可比性。术中，LA组的皮质醇和促肾上腺皮质激素水平显著更高（均P <.001）。CACC使GA组（P =.019）和LA组（P =.006）的术中皮质醇水平升高。然而，在接受颈动脉分流的患者中，这种效应被消除（GA组，P =.779；LA组，P = 1.0）。在术后早期，两组之间没有差异。术后第1天，两组的应激反应均被消除。LA组和GA组术中催乳素水平均升高，并在术后第1天恢复到术前值。GA组的催乳素水平更高（术中P =.003，术后P <.001）。GA组和LA组术后第1天和第2天C反应蛋白均显著升高，并在第3天开始下降，两组在任何时候均无差异。血流动力学变异性以及包括个体外科医生在内的考虑到的危险因素不是显著变量。仅在催乳素分泌方面发现了与性别相关的差异。手术时间对持续时间>120分钟的手术有影响。3例患者发生术中神经事件，与无症状患者相比，CACC后皮质醇值更高。
LA下术中手术应激更高，LA和GA下颈动脉分流均可减轻这种应激。术后2小时内，麻醉方式对手术创伤不再有任何影响。无论麻醉类型如何，对CEA的应激反应在24小时内均被消除。术中应激反应，即高皮质醇血症，与CACC期间的亚临床和临床脑灌注不足/缺血直接相关。因此，减轻对CEA的应激反应可能会降低脑缺血事件的发生率。
