Anesthesia for Revascularization Surgery 

Revascularization is a procedure to restore blood flow to blocked arteries or veins which falls into two main categories: less-invasive interventional procedures and traditional surgeries. These can take on the form of an angioplasty, atherectomy, bypass surgery, or endarterectomy. The goals of revascularization surgery can include relieving pain, helping to keep a patient active, healing wounds related to lack of blood flow, saving limbs from amputation, and improving one’s day-to-day life. Anesthesia for revascularization surgery is a critical aspect of surgery, affecting outcomes, and continues to be a delicate endeavor. This is of particular importance in light of the fact that revascularization surgeries are associated with a high rate of morbidity and mortality.  

In surgical contexts, neuraxial anesthesia has been shown to improve coagulation, increase peripheral blood flow, avoid the use of airway instrumentation and mechanical ventilation, and minimize surgical stress responses. Compared with general anesthesia, neuraxial anesthesia may reduce the risk of pneumonia, venous thromboembolism, and mortality following different types of surgery. A recent study has further revealed that using neuraxial anesthesia for lower limb revascularization surgery, compared with general anesthesia, was associated with decreased 30-day mortality and a shorter hospital stay [1]. These findings may be linked to the observation of reduced cardiopulmonary and renal complications following the administration of neuraxial anesthesia. A population-based comparative effectiveness study demonstrated that the use of neuraxial instead of general anesthesia in patients undergoing lower extremity arterial revascularization surgery was associated with decreased rates of mortality, complications, and readmissions, in addition to a shorter length of stay and minimized health care system costs [2]. Overall, such results support the increased use of neuraxial anesthesia in patients undergoing these surgeries.  

In parallel, one study demonstrated that in the context of myocardial revascularization, regional epidural thoracic anesthesia, an anesthetic method which was successfully carried out on a large number of patients selected for the study, may be an effective anesthetic regimen [3]. Further research, from studies of lower limb revascularization surgeries in fragile patients, has shown that local anesthesia should be considered a top choice among certain high-risk patients [4]. 

However, some research has found that the choice of anesthesia in revascularization surgery has no effect on surgical outcome. One review concluded that the quality of anesthetic practice rather than specific technique per se has the greatest influence on patient outcome [5]. Consistently, a recent study found that perioperative outcomes are more likely to be influenced by the thorough anesthetic management of heart rate, temperature, arterial pressure, and pain rather than a specific anesthetic technique [6]. This was confirmed by another study showing that, although neuraxial anesthesia may reduce the incidence of pneumonia, no conclusions can be firmly drawn as regards the differences between neuraxial and general anesthesia with regard to rates of mortality, myocardial infarction, or lower limb amputation [7]. 

In conclusion, anesthesia should be carefully selected and administered for revascularization surgery. Neuraxial anesthesia in particular may outperform general anesthesia in the context of certain specific types of revascularization surgeries. In the future however, large, randomized trials are warranted to confirm and expand these research results.  

References 

1. Roberts, D. J. et al. Association between neuraxial anaesthesia or general anaesthesia for lower limb revascularisation surgery in adults and clinical outcomes: Population based comparative effectiveness study. BMJ (2020). doi:10.1136/bmj.m4104 

2. Roberts, D. J. et al. Type of Anesthesia for Lower Extremity Arterial Revascularization Surgery: A Population-Based Comparative Effectiveness Study. J. Vasc. Surg. (2019). doi:10.1016/j.jvs.2019.07.027 

3. Souto, G. L. L. et al. Myocardial Revascularization Surgery with Regional Anesthesia Without an Endotracheal Tube in Conscious Patients. Arq. Bras. Cardiol. (2002). doi:10.1590/s0066-782×2002001200009 

4. Kontopodis, N. et al. The use of local anesthesia to perform lower limb revascularization in the fragile patient with critical limb Ischemia. G. di Chir. (2018). doi:10.138/gchir/2018.39.2.077 

5. Tovey, G. & Thompson, J. P. Anaesthesia for lower limb revascularization. Contin. Educ. Anaesthesia, Crit. Care Pain (2005). doi:10.1093/bjaceaccp/mki024 

6. Fraser, K. & Raju, I. Anaesthesia for lower limb revascularization surgery. BJA Educ. (2015). doi:10.1093/bjaceaccp/mku042 

7. Barbosa, F. T., Jucá, M. J., Castro, A. A. & Cavalcante, J. C. Neuraxial anaesthesia for lower-limb revascularization. Cochrane Database of Systematic Reviews (2013). doi:10.1002/14651858.CD007083.pub3