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L'anesthésie loco-régionale neuraxiale et la chirurgie vasculaire: les bénéfices

Département d'anesthésie-réanimation, Hôpital Maisonneuve-Rosemont, Montréal, Québec, Canada.

Adresser la correspondance à: Dr. Pierre Drolet, département d'anesthésie-réanimation, Hôpital Maisonneuve- Rosemont, 5415 boul. de l'Assomption, Montréal, Québec, H1T 2M4, Canada. Téléphone: 514-252-3426; Télécopieur: 514-252-3542; Courriel: pdrolet{at}aei.ca

Purpose: To assess the advantages of neuraxial blockade (NB) during and after vascular surgery and to confront them with the risk of epidural or spinal hematoma.

Main findings: NB may reduce the risk of thrombotic occlusion following lower extremity vascular reconstruction. This effect of NB may be attributed to reduced hypercoagulability, decreased peripheral resistance and increased graft flow. In patients under general anesthesia, only those authors using an aggressive perioperative management (pulmonary artery catheter monitoring, intensive care unit admission) were able to report grafts patency rates similar to those obtained with NB.

NB facilitates the modulation of the hemodynamic and hormonal stress responses during the perioperative period. It also produces superior postoperative analgesia. Still, the impact of NB on cardiac morbidity following aortic reconstructive surgery remains open to debate.

Only very few cases of epidural hematomas associated to NB following vascular surgery have been reported. They implicated patients who received either fibrinolytic medication, continuous heparin infusion, or both. Low molecular weight heparins may increase the risk or epidural hematoma and, should their administration become more frequent during vascular surgery, the safety of NB would then have to be reassessed.

Conclusion: NB during vascular surgery is a safe and well-established practice. It offers many theoretical and demonstrated advantages. NB is particularly beneficial and economical for lower extremity vascular reconstrutcion. Still, NB may not be the best approach if the administration of fibrinolityc medication or prolonged heparin infusion is contemplated.