Carotid Artery Surgery in Older and Oldest-Old Patients

Relevance. Atherosclerotic involvement of the carotid arteries accounts for 17-20% of all lesions among the total number of lesions in all branches of the aorta. It is the main cause of ischemic strokes (30-52% of cases). Carotid endarterectomy is one of the radical methods for treating and preventing this complication, as there is currently no other sufficiently effective pharmacological treatment.

Aim to investigate the immediate outcomes of surgical treatment, assess the safety and rationale of using regional anesthesia in performing carotid endarterectomy in older patients (aged 60 and above).

Materials and methods. The study included 193 patients with brachiocephalic artery pathology who were hospitalized in the Vascular Surgery Department of the War Veterans Hospital No. 2 in Moscow from March 2021 to December 2022: 116 (60.1%) males, 77 (39.9%) females, aged 60 to 96 years, with a mean age of 78.5 years. The cause of carotid artery involvement was atherosclerosis and atherosclerosis combined with pathological tortuosity of the vessel.

When determining the indications for surgery on the carotid artery, the clinical picture, degree of stenosis (70% or more), characteristics of the atherosclerotic plaque, and linear flow velocity (LFV) on the pathologically tortuous vessel were taken into account.

All patients underwent preoperative consultation with a geriatrician for comprehensive geriatric assessment (CGA) and medication review. They also underwent CT angiography of the brachiocephalic arteries with evaluation of the Willis Circle, native CT of the brain, esophagogastroduodenoscopy, echocardiography, carotid ultrasound, and consultations with a cardiologist, neurologist, and medical psychologist. General anesthesia was used in 8 cases (3.9%) and regional anesthesia in 185 cases (96.1%) during the surgical intervention. Regional anesthesia involved a combination of conduction and local infiltrative anesthesia, including deep (cervical and/or anterior approach) and superficial cervical plexus block and infiltration of soft tissues in the area of the mandibular angle.

Results. The mortality rate was 2.0% (4 patients), with one death due to recurrent stroke and three deaths due to acute myocardial infarction. There were 3 cases of stroke (1.5%): one patient died, one underwent thrombectomy within 2 hours with regression of neurological symptoms and full recovery, and one patient had neurological symptoms resolved one month after the stroke. Two patients (1.0%) required repeat surgery due to bleeding. No wound-related issues were noted.

Conclusion. The implementation of geriatric scales in surgical practice allows for a more careful selection of patients for surgical treatment based on their physical and cognitive status rather than solely on age, which helps minimize the risks of complications in the perioperative and postoperative periods. The use of regional anesthesia with simultaneous assessment of tolerance to cerebral ischemia allows for reliable monitoring of cerebral protection during temporary occlusion of the carotid arteries, enabling timely measures for preventing intraoperative ischemic injuries, such as the use of temporary bypass shunts. The safety of the technique allows its application in older patients with comorbidities and high anesthesiological risk. Currently, general anesthesia remains the main choice for analgesia during carotid artery surgeries. Regional anesthesia is still a subject of discussion in carotid artery surgeries. Studies and articles highlight both the advantages and disadvantages of each analgesic method. In our daily practice, regional anesthesia accounts for more than 95% of the total analgesic approach in carotid endarterectomy.