The retrojugular route: the ideal exposure for carotid endarterectomy performed under locoregional anesthesia

Abstract

Background: Scientific evidence exists to support the claim that either general o regional anesthesia can be safely used for CEA: each of the techniques has either theoretical and practical advantages or drawbacks. Since the issue of whether, for CEA, one anesthetic technique is better than another has not yet been explored by randomized trials, any contribution that could reduce the disadvantages of any of the two approaches may contribute to overcome individual diffidence and visceral antagonism. The proposed approach represents a technical improvement of locoregional CEA technique.

Methods: One hundred consecutive patients undergoing elective or urgent primary CEA under locoregional anesthesia were prospectively randomized in two equal size groups. In group 1 traditional (medial) approach to carotid bifurcation was employed; in group 2 the retrojugular approach (RJA) was used. Surgical and anesthesia scores were developed to assess the differences between the two groups in terms of surgical ease, the quality of exposure, patients comfort, level and quality of anesthesia.

Results: Demographic and clinical characteristics of group 1 and group 2 patients were comparable. No major complication or death was observed in this series. Significant score differences were observed in favour of the retrojugular route. Using this route an improved and wider exposure was obtained, moreover, we achieved a better analgesia, with lesser additional anesthetic doses requirements, a faster approach to the carotid bifurcation, an enhanced patient comfort and a reduced interference on the surgical procedure by deglutition movements.

Conclusions: The retrojugular route represents the ideal route for locoregional CEA; this exposure, with respect to the traditional approach, minimizes many of the disadvantages commonly considered as major deterrents of regional anesthesia for carotid surgery.