Outcomes of Local and Regional Anesthesia for Superficialization of Brachiobasilic Arteriovenous Fistulas.

BACKGROUND: Superficialization, the second stage of a two-stage brachiobasilic arteriovenous fistula (BB-AVF), can be performed under local (LA), regional (RA), or general anesthesia (GA). Given the numerous comorbidities in patients with end-stage renal disease (ESRD), our preference is to use RA or LA when feasible. Our goal was to review the success rate of RA and LA, need for conversion to GA, and cardiac morbidity and mortality for BB-AVF superficialization. METHODS: We performed a retrospective cohort analysis of patients who underwent BB-AVF creation with second-stage superficialization over a 4-year period. The primary outcome measures included need for conversion to GA, myocardial infarction (MI), and 30-day mortality. A secondary outcome was total operative time (time from preoperative briefing to the time the patient left the operating room). We analyzed the data using Fisher Exact test for categorical data and nonparametric analysis for continuous data. RESULTS: There were 42 patients who underwent BB-AVF superficialization. The median age was 56 years, with a mean body mass index of 29. Most patients were male (55%) and predominantly Hispanic/Latino (60%). RA was utilized in 35 patients (83%), LA in 5 (12%), and GA in 2 (5%). The conversion rate from RA to GA was 0% and was 20% (n = 1) from LA to GA. There were no postoperative MI or deaths. There was no significant difference in total operative time (219.6 min for RA, 234.5 min for LA, and 278 min for GA, (P = 0.37)). CONCLUSIONS: Local and/or regional anesthesia can be successfully used in the majority of patients undergoing BB-AVF superficialization. LA and RA are associated with negligible cardiac morbidity and mortality. Conversion from RA to GA is rare. Use of RA does not result in a longer total operative time.

Endovascular abdominal aortic aneurysm repair with general versus local anesthesia: a comparison of cardiopulmonary morbidity and mortality rates.

PURPOSE: The purpose of this study was to compare the cardiopulmonary morbidity and mortality rates after endovascular abdominal aortic aneurysm (EAAA) repair with local anesthesia (LA) with intravenous sedation versus general anesthesia (GA). METHODS: Data from patients who underwent elective infrarenal EAAA repair between June 1996 and October 2000 were retrospectively reviewed. Patients with two or more Eagle clinical cardiac risk factors were considered to be at increased risk for a major postoperative cardiac event. Univariate and multivariate analyses for major cardiac and pulmonary morbidity and mortality rates were analyzed with respect to anesthetic type (GA versus LA), age, size of aneurysm, mean number of Eagle risk factors, and presence of two or more cardiac risk factors. RESULTS: Two hundred twenty-nine patients underwent EAAA repair. The GA (158 patients) and LA (71 patients) groups were significantly different with respect to mean age (73 versus 76 years; P =.01) and mean number of cardiac risk factors per patient (1.2 versus 1.6; P =.002). No difference was seen in the overall cardiopulmonary complication rate (13% for GA and 19% for LA; P =.3), pulmonary complication rate (3.8% for GA and 7% for LA; P =.3), or cardiopulmonary mortality rate (3.2% for GA and 2.8% for LA; P =.9). The major cardiac event rate was higher in patients with two or more Eagle risk factors (22%) versus those patients with one or less Eagle risk factors (3.4%; P <.001), irrespective of anesthetic type. In analysis of patients with one or less Eagle risk factors, no difference was seen in the major cardiac event rate by anesthetic type (3% for GA and 5% for LA; P =.6). Also, no difference was seen in major cardiac events in patients with two or more Eagle risk factors by anesthetic type (24% for GA and 22% for LA). On multivariate analysis, the mean number of Eagle risk factors per patient (P <.0001) and the presence of two or more Eagle risk factors were associated with major cardiac and cardiopulmonary complications, whereas age, size of AAA, and anesthetic type were not. CONCLUSION: No difference exists in overall cardiac and pulmonary morbidity and mortality rates after EAAA repair in comparison of GA and LA. The presence of two or more preoperative cardiac risk factors significantly increases the risk of a major postoperative cardiac event.