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L'anesthésie loco-régionale neuraxiale ne devrait plus être utilisée en chirurgie vasculaire

Département d'anesthésie-réanimation, Hôpital Avicenne, France.

Adresser la correspondance à: Dr Charles Marc Samama, département d'anesthésie-réanimation, Hôpital Avicenne, 125 route de Stalingrad, 93009 Bobigny Cedex, France. Téléphone: 33-1-48955591; Télécopieur: 33-1-48955589; Courriel: cmsamama{at}invivo.edu

Objectives: Neuraxial blockade (spinal or epidural anesthesia) is still widely used in patients undergoing vascular surgery. However, the combined administration of anticoagulants and antiplatelet agents may compromise the safety of this technique with regards to the potential occurrence of a spinal or of an epidural hematoma. We review the benefits and risks of neuraxial blockade in light of the evolution of anticoagulation for vascular surgery.

Main findings: Vascular surgery generally requires a high level of intraoperative anticoagulation. An increasing number of patients are also treated pre and post-operatively with antiplatelet agents. Their administration cannot be interrupted without serious risks to the patients' cardiovascular system and, further their continued use during surgery may improve graft permeability. Recent reports have emphasized the danger of neuraxial anesthesia in patients receiving low dose anticoagulation. So, high doses of heparins should carry an ever higher risk of serious complications in patients undergoing neuraxial blockade. Furthermore, no published data has ever demonstrated convincingly the benefit of either epidural or spinal anesthesia over general anesthesia. No differences have ever been documented in terms of cardio-vascular morbidity, graft patency, and mortality.

Conclusion: Routine neuraxial blockade cannot be recommended in patients undergoing vascular surgery. The decision to perform a neuraxial block in such a patient may only be taken on a case by case basis, after careful consideration of expected benefits and potential risks.