A Novel Approach To Preventing Intraoperative Bradycardia During TCAR
Jamal Malik, DO, Robert Carter, MD, Loki Skylizard, MD, Karl Stark, MD, Jonathan Wilson, DO, Scott Kujath, MD.
Midwest Aortic & Vascular Institute, North Kansas City, MO, USA.
Bradycardia is a known complication of carotid artery manipulation. Profound bradycardia and associated hypotension are common during transcarotid artery revascularization (TCAR). During open carotid endarterectomy, the carotid bulb is often injected with local anesthetic for intraoperative management of bradycardia. Similarly, ultrasound guidance can be used to percutaneously inject the carotid bifurcation during TCAR. We retrospectively reviewed the effect of ultrasound guided local anesthetic injection at the carotid bifurcation to anesthetize the carotid sinus and prevent intraoperative bradycardia during TCAR. We compared the incidence of bradycardia in TCAR patients with and without carotid sinus anesthetic.
A single practice retrospective review was performed of all carotid intervention using a TCAR approach. A total of 63 TCAR patients were identified between November 2017 and August 2020. Of these, 16 underwent prophylactic ultrasound guided carotid sheath injection with 5 ml of 0.5% bupivacaine prior to any carotid manipulation. Major comorbidities such as hypertension, diabetes mellitus, previous CVA, and tobacco use were also evaluated. Intra-operative anesthesia reports were analyzed including preoperative heart rate, heart rate prior to injection, and heart rate throughout the procedure.
Patients who received intraoperative bupivacaine injection had a significant decrease in bradycardia episodes. No patients (0/16) who were injected had bradycardia versus 24/47 non-injected patients had documented bradycardia. The two groups had similar preoperative risk factors. There was no identifiable correlation with incidence of bradycardia and numerous comorbidities.
Intraoperative bradycardia and secondary hypotension are an immediate concern during any carotid intervention. These hemodynamic changes can be significantly reduced during TCAR with ultrasound guided carotid bifurcation anesthetic injection. We recommend considering injection of local anesthetic at the carotid bifurcation prior to any carotid manipulation to avoid bradycardia. Further research will focus on the effects of different local anesthetics and volumes for the injection, as well as post-operative blood pressure management.
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