{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T19:21:51Z","timestamp":1785439311779,"version":"3.56.0"},"reference-count":46,"publisher":"MDPI AG","issue":"24","license":[{"start":{"date-parts":[[2024,12,12]],"date-time":"2024-12-12T00:00:00Z","timestamp":1733961600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background\/Objectives: There is an ongoing debate about the most advantageous anesthesia technique for carotid endarterectomy (CEA). From an anesthesiologic perspective, locoregional anesthesia (LRA) appears to offer significant benefits. However, the learning curve and complication rates for anesthesiologists newly performing ultrasound-guided LRA for CEA remain unclear and are to be examined in greater detail in this study. Methods: This retrospective, single-center study included all consecutive LRA administrations for CEA following the introduction of this procedure at a district hospital in Germany from November 2013 to November 2017. Nine board-certified anesthesiologists, initially inexperienced in LRA for CEA but with prior experience in other ultrasound-guided peripheral nerve blocks (PNBs), received theoretical training and supervision during their first six combined deep and superficial cervical plexus blocks under ultrasound guidance. The primary endpoint was the incidence of insufficient block quality, indicated by pain and restlessness or the additional need for analgesics. Secondary endpoints included LRA-associated complications. Patients were divided into four groups based on the number of previously performed LRA procedures by the attending anesthesiologist. Results: In 83 patients, LRA was performed by initially inexperienced anesthesiologists. Group A (patients managed by anesthesiologists performing their 1st to 3rd cervical plexus blockades) included 21 patients, Group B (blockades 4\u20136) included 12 patients, Group C (blockades 7\u20139) included 9 patients, and Group D (\u226510 blockades) included 41 patients, respectively. The overall complication rate was 22% (18\/83). Insufficient block quality occurred in 18.1% of patients (15\/83), resulting in three conversions to general anesthesia (3.6%). Additional complications included dysphagia (n = 2) and Horner\u2019s syndrome (n = 1). The incidence of insufficient block quality was significantly reduced (p = 0.008) after performing the first three blockades. Conclusions: Ultrasound-guided cervical plexus block for CEA appears to be a rapidly learnable anesthesia technique for anesthesiologists experienced in other ultrasound-guided PNBs, with a low risk of complications. After three supervised blockades, the failure rate of LRA decreases significantly.<\/jats:p>","DOI":"10.3390\/jcm13247557","type":"journal-article","created":{"date-parts":[[2024,12,12]],"date-time":"2024-12-12T04:52:49Z","timestamp":1733979169000},"page":"7557","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Learnability of Ultrasound-Guided Locoregional Anesthesia for Carotid Endarterectomy"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0009-0003-6110-2713","authenticated-orcid":false,"given":"Benjamin","family":"Seybold","sequence":"first","affiliation":[{"name":"Department of Anesthesiology, Heidelberg University Hospital, Medical Faculty, University of Heidelberg, 69120 Heidelberg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nils","family":"Gaier","sequence":"additional","affiliation":[{"name":"Merck KGaA, 64293 Darmstadt, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andreas","family":"Ofenloch","sequence":"additional","affiliation":[{"name":"Department of Vascular Surgery, District Hospital Bergstrasse, 64646 Heppenheim, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dittmar","family":"Boeckler","sequence":"additional","affiliation":[{"name":"Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Medical Faculty, University Heidelberg, 69120 Heidelberg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Armin","family":"Kalenka","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Heidelberg University Hospital, Medical Faculty, University of Heidelberg, 69120 Heidelberg, Germany"},{"name":"District Hospital Bergstrasse, 64646 Heppenheim, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0127-2783","authenticated-orcid":false,"given":"Mascha O.","family":"Fiedler-Kalenka","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Heidelberg University Hospital, Medical Faculty, University of Heidelberg, 69120 Heidelberg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2024,12,12]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"2132","DOI":"10.1016\/S0140-6736(08)61699-2","article-title":"General anaesthesia versus local anaesthesia for carotid surgery (GALA): A multicentre, randomised controlled trial","volume":"372","author":"Group","year":"2008","journal-title":"Lancet"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"219","DOI":"10.1053\/j.jvca.2019.03.029","article-title":"General Anesthesia Versus Local Anesthesia in Carotid Endarterectomy: A Systematic Review and Meta-Analysis","volume":"34","author":"Harky","year":"2020","journal-title":"J. Cardiothorac. Vasc. Anesth."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1280","DOI":"10.1111\/anae.14320","article-title":"Meta-analysis and trial sequential analysis of local vs. general anaesthesia for carotid endarterectomy","volume":"73","author":"Hajibandeh","year":"2018","journal-title":"Anaesthesia"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1016\/j.jvs.2016.01.047","article-title":"Anesthetic type and risk of myocardial infarction after carotid endarterectomy in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST)","volume":"64","author":"Hye","year":"2016","journal-title":"J. Vasc. Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"3439","DOI":"10.1161\/STROKEAHA.119.026320","article-title":"Associations of Perioperative Variables With the 30-Day Risk of Stroke or Death in Carotid Endarterectomy for Symptomatic Carotid Stenosis","volume":"50","author":"Knappich","year":"2019","journal-title":"Stroke"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1016\/j.ejvs.2022.04.011","article-title":"Editor\u2019s Choice\u2014European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease","volume":"65","author":"Naylor","year":"2023","journal-title":"Eur. J. Vasc. Endovasc. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"4S","DOI":"10.1016\/j.jvs.2021.04.073","article-title":"Society for Vascular Surgery clinical practice guidelines for management of extracranial cerebrovascular disease","volume":"75","author":"AbuRahma","year":"2022","journal-title":"J. Vasc. Surg."},{"key":"ref_8","first-page":"309462","article-title":"Different Learning Curves for Axillary Brachial Plexus Block: Ultrasound Guidance versus Nerve Stimulation","volume":"2010","author":"Luyet","year":"2010","journal-title":"Anesthesiol. Res. Pract."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"92","DOI":"10.1016\/j.bjae.2022.12.002","article-title":"The failed peripheral nerve block","volume":"23","author":"Bottomley","year":"2023","journal-title":"BJA Educ."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"415","DOI":"10.1093\/bja\/aem171","article-title":"Regional anaesthesia for carotid endarterectomy: An audit over 10 years","volume":"99","author":"Hakl","year":"2007","journal-title":"Br. J. Anaesth."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"775","DOI":"10.1093\/bja\/aeh550","article-title":"Correct nomenclature of superficial cervical plexus blocks","volume":"92","author":"Telford","year":"2004","journal-title":"Br. J. Anaesth."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"274","DOI":"10.4097\/kja.d.18.00143","article-title":"Cervical plexus block","volume":"71","author":"Kim","year":"2018","journal-title":"Korean J. Anesthesiol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"616","DOI":"10.1097\/AAP.0b013e3181b4d0aa","article-title":"Sonoanatomy of the cervical spinal nerve roots: Implications for brachial plexus block","volume":"34","author":"Narouze","year":"2009","journal-title":"Reg. Anesth. Pain Med."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"964","DOI":"10.1213\/ANE.0b013e3181c91ea0","article-title":"An anatomical basis for blocking of the deep cervical plexus and cervical sympathetic tract using an ultrasound-guided technique","volume":"110","author":"Usui","year":"2010","journal-title":"Anesth. Analg."},{"key":"ref_15","first-page":"806","article-title":"Cervical Plexus Blocks","volume":"52","author":"Seidel","year":"2017","journal-title":"Anasthesiol. Intensivmed. Notfallmed Schmerzther."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"544","DOI":"10.1016\/j.rapm.2004.08.014","article-title":"The learning curve associated with a simulated ultrasound-guided interventional task by inexperienced anesthesia residents","volume":"29","author":"Sites","year":"2004","journal-title":"Reg. Anesth. Pain Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"170","DOI":"10.1136\/bmj.310.6973.170","article-title":"Multiple significance tests: The Bonferroni method","volume":"310","author":"Bland","year":"1995","journal-title":"BMJ"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"187","DOI":"10.1590\/S0034-70942009000200006","article-title":"Learning curve for the ultrasound anatomy of the brachial plexus in the axillary region","volume":"59","author":"Helayel","year":"2009","journal-title":"Rev. Bras. Anestesiol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"76","DOI":"10.1007\/s00540-013-1680-y","article-title":"Learning curve of medical students in ultrasound-guided simulated nerve block","volume":"28","author":"Kim","year":"2014","journal-title":"J. Anesth."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"118","DOI":"10.1002\/ca.22340","article-title":"Anastomoses between lower cranial and upper cervical nerves: A comprehensive review with potential significance during skull base and neck operations, part I: Trigeminal, facial, and vestibulocochlear nerves","volume":"27","author":"Shoja","year":"2014","journal-title":"Clin. Anat."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"131","DOI":"10.1002\/ca.22342","article-title":"A comprehensive review with potential significance during skull base and neck operations, Part II: Glossopharyngeal, vagus, accessory, and hypoglossal nerves and cervical spinal nerves 1-4","volume":"27","author":"Shoja","year":"2014","journal-title":"Clin. Anat."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1016\/S0034-9356(11)70003-2","article-title":"Ultrasound-guided axillary brachial plexus block: Learning curve and results","volume":"58","author":"Morros","year":"2011","journal-title":"Rev. Esp. Anestesiol. Reanim."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"164","DOI":"10.1111\/j.1399-6576.2011.02547.x","article-title":"Developing the skill of endotracheal intubation: Implication for emergency medicine","volume":"56","author":"Bernhard","year":"2012","journal-title":"Acta Anaesthesiol. Scand."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"671","DOI":"10.1097\/AAP.0000000000000486","article-title":"A Randomized Controlled Trial of Ultrasound Versus Nerve Stimulator Guidance for Axillary Brachial Plexus Block","volume":"41","author":"Barrington","year":"2016","journal-title":"Reg. Anesth. Pain. Med."},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Cataldo, R., Carassiti, M., Costa, F., Martuscelli, M., Benedetto, M., Cancilleri, F., Marinozzi, A., and Martinelli, N. (2012). Starting with ultrasonography decreases popliteal block performance time in inexperienced hands: A prospective randomized study. BMC Anesthesiol., 12.","DOI":"10.1186\/1471-2253-12-33"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"534","DOI":"10.1097\/AAP.0b013e3181ae72e8","article-title":"Preliminary results of the Australasian Regional Anaesthesia Collaboration: A prospective audit of more than 7000 peripheral nerve and plexus blocks for neurologic and other complications","volume":"34","author":"Barrington","year":"2009","journal-title":"Reg. Anesth. Pain Med."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1097\/AAP.0b013e31823dc340","article-title":"Ultrasound-guided regional anesthesia performance in the early learning period: Effect of simulation training","volume":"37","author":"Niazi","year":"2012","journal-title":"Reg. Anesth. Pain Med."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"631","DOI":"10.1016\/j.jvs.2015.03.074","article-title":"Examination of regional anesthesia for carotid endarterectomy","volume":"62","author":"Pasin","year":"2015","journal-title":"J. Vasc. Surg."},{"key":"ref_29","first-page":"323","article-title":"Carotid endarterectomy: Regional versus general anesthesia","volume":"46","author":"Andersen","year":"1980","journal-title":"Am. Surg."},{"key":"ref_30","first-page":"441","article-title":"Incidence of and indications for conversion of cervical plexus block to general anesthesia in patients undergoing carotid surgery: A single center experience","volume":"56","author":"Sindjelic","year":"2015","journal-title":"J. Cardiovasc. Surg."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"159","DOI":"10.1093\/bja\/aem160","article-title":"Superficial or deep cervical plexus block for carotid endarterectomy: A systematic review of complications","volume":"99","author":"Pandit","year":"2007","journal-title":"Br. J. Anaesth."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1016\/j.jvs.2015.02.036","article-title":"Ultrasound-guided regional anesthesia for carotid endarterectomy induces early hemodynamic and stress hormone changes","volume":"62","author":"Hoefer","year":"2015","journal-title":"J. Vasc. Surg."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1136\/rapm-2021-102851","article-title":"Depth of cervical plexus block and phrenic nerve blockade: A randomized trial","volume":"47","author":"Opperer","year":"2022","journal-title":"Reg. Anesth. Pain Med."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"317","DOI":"10.1053\/j.jvca.2015.07.032","article-title":"Comparison of Combined (Deep and Superficial) and Intermediate Cervical Plexus Block by Use of Ultrasound Guidance for Carotid Endarterectomy","volume":"30","author":"Sagdic","year":"2016","journal-title":"J. Cardiothorac. Vasc. Anesth."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"442","DOI":"10.1093\/bja\/aep012","article-title":"Arterial pressure management and carotid endarterectomy","volume":"102","author":"Stoneham","year":"2009","journal-title":"Br. J. Anaesth."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"140","DOI":"10.1016\/j.annfar.2008.12.013","article-title":"Ultrasound and regional anaesthesia","volume":"28","author":"Delaunay","year":"2009","journal-title":"Ann. Fran\u00e7aises D\u2019Anesth\u00e9sie R\u00e9animation"},{"key":"ref_37","first-page":"283","article-title":"Regional anesthesia for carotid surgery: An overview of anatomy, techniques and their clinical relevance","volume":"66","author":"Kokofer","year":"2017","journal-title":"Anaesthesist"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"526","DOI":"10.23736\/S0375-9393.21.16227-3","article-title":"Ultrasound-guided cervical plexus block: Understanding the cervical fasciae to clarify the nomenclature of this technique","volume":"88","author":"Scimia","year":"2022","journal-title":"Minerva Anestesiol."},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"Ratnayake, A., Abeysundara, A., Samarasinghe, B., Rathnayake, J., Samarasinghe, S., Perera, R., and Bandara, C. (2024). Use of intermediate cervical plexus block in carotid endarterectomy -an alternative to deep cervical plexus block: A case series. BMC Anesthesiol., 24.","DOI":"10.1186\/s12871-024-02674-8"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"733","DOI":"10.1093\/bja\/aeg250","article-title":"Spread of injectate with superficial cervical plexus block in humans: An anatomical study","volume":"91","author":"Pandit","year":"2003","journal-title":"Br. J. Anaesth."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"219","DOI":"10.1177\/0310057X9001800211","article-title":"Carotid endarterectomy under cervical plexus block--a prospective clinical audit","volume":"18","author":"Davies","year":"1990","journal-title":"Anaesth. Intensive Care"},{"key":"ref_42","first-page":"36","article-title":"Anesthesia residents\u2019 preference for learning interscalene brachial plexus block (ISBPB): Traditional Winnie\u2019s technique vs. ultrasound-guided technique","volume":"163","author":"Awad","year":"2011","journal-title":"Stud. Health Technol. Inform."},{"key":"ref_43","first-page":"413","article-title":"Curriculum development for an advanced regional anesthesia education program: One institution\u2019s experience from apprenticeship to comprehensive teaching","volume":"22","author":"Ouanes","year":"2014","journal-title":"Middle East J. Anaesthesiol."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"13","DOI":"10.4097\/kja.d.18.00317","article-title":"Simulation-based ultrasound-guided regional anesthesia curriculum for anesthesiology residents","volume":"72","author":"Kim","year":"2019","journal-title":"Korean J. Anesthesiol."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"776","DOI":"10.1016\/j.annfar.2010.08.010","article-title":"Anxiety: An independent factor of axillary brachial plexus block failure?","volume":"29","author":"Fuzier","year":"2010","journal-title":"Ann. Fran\u00e7aises D\u2019Anesth\u00e9sie R\u00e9animation"},{"key":"ref_46","first-page":"627","article-title":"Importance of instrument-based neuromonitoring during carotid surgery using regional anesthesia","volume":"66","author":"Kokofer","year":"2017","journal-title":"Anaesthesist"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/13\/24\/7557\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T16:53:08Z","timestamp":1760115188000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/13\/24\/7557"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,12,12]]},"references-count":46,"journal-issue":{"issue":"24","published-online":{"date-parts":[[2024,12]]}},"alternative-id":["jcm13247557"],"URL":"https:\/\/doi.org\/10.3390\/jcm13247557","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,12,12]]}}}