Anesthetic type and risk of myocardial infarction after carotid endarterectomy in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST)

Abstract

Objectives Carotid endarterectomy (CEA) is usually performed under general anesthesia (GA) although some advocate regional anesthesia (RA) to reduce hemodynamic instability, allow neurologic monitoring and selective shunting. RA does not reduce risk of periprocedural stroke or death, although some series show a reduction in myocardial infarction (MI). We investigated the association of anesthesia type and periprocedural MI among patients receiving GA or RA for CEA and patients undergoing carotid artery stenting (CAS) in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Methods Between 2000 and 2008, 1151 patients underwent CEA (anesthetic type available on 1149 patients) and 1123 patients underwent CAS within 30 days of randomization in CREST. CEA patients were categorized by anesthetic type (GA vs RA). CREST defined protocol MI as chest pain or ECG change plus biomarker evidence of MI and total MI was defined as protocol MI plus biomarker-positive (biomarker +) only MI. The incidence of protocol MI and total MI were compared between patients undergoing CEA under GA, RA and those undergoing CAS. Other study endpoints were similarly compared. Differences in baseline characteristics and periprocedural events were also evaluated among the three groups. Logistic regression was used to assess group differences adjusting for age and symptomatic status. Results The three groups had similar demographic risk factors except for prevalence of symptomatic carotid stenosis, which was lowest in the CEA-RA group (P=.03). Of the 111 patients in the in the CEA-RA group, there were not any protocol MI’s and only 2 biomarker + only MI’s for an overall incidence of 1.8%, similar to the 1.7% overall incidence seen in patients undergoing CAS. In contrast, the combined incidence of protocol and biomarker + MI’s in the 1038 patients in the CEA-GA group was significantly higher at 3.4% (P=.04), twice the risk of protocol MI and biomarker + only MI when compared to those undergoing CAS (OR, 2.01; 95%, CI 1.14-3.54). Direct comparison of the MI incidence between CEA-RA and CEA-GA showed no statistical difference. Patients undergoing CEA under GA had lower odds of a periprocedural stroke (OR, 0.48; 95% CI 0.28-0.79) and stroke or death (OR, 0.46; 95% CI 0.27-0.76) when compared to those undergoing CAS but were not significantly different than those undergoing CEA-RA. Conclusions In CREST, patients undergoing CEA under RA had similar risk of periprocedural MI as those undergoing CAS while the risk for CEA-GA was twice that compared to patients undergoing CAS. Nevertheless, since periprocedural MI is one of the few variables favoring CAS over CEA, and has been associated with decreased long term survival, RA should be seriously considered for patients undergoing CEA.

Increased resource utilization and overall morbidity are associated with general versus regional anesthesia for carotid endarterectomy in data collected by the Michigan Surgical Quality Collaborative

“…A recent study of the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) cohort by Hye et al showed increased periprocedural MI with GA vs RA. 9 Similarly, two studies of the National Surgical Quality Improvement Program database by Leichtle et al and Kfoury et al suggested increased cardiac morbidity after GA vs RA for CEA. 6,8 Nevertheless, a separate study of the National Surgical Quality Improvement Program database by Schechter et al showed no difference in patient outcomes.…”

“…[2][3][4] The General Anesthesia versus Local Anesthesia for Carotid Surgery (GALA) trial in 2008 was recognized as a landmark study showing no difference in morbidity or mortality under local anesthesia vs GA. 5 The ideal anesthetic technique, however, has been the subject of intense study, with several studies reporting conflicting results and some suggesting a tendency toward increased cardiac morbidity with GA. [6][7][8][9] Advocates for performing CEA under RA cite reduction in hemodynamic instability and indisputably reliable neurologic monitoring, but many still prefer to employ GA as benefits of RA have not been clearly demonstrated, reliable RA may not be available in all centers, and a certain amount of movement by the patient during the procedure may not be uniformly tolerated.…”

Association of Primary Anesthesia Type with Postoperative Adverse Events After Transcarotid Artery Revascularization

“…A priori, the authors expected a significant benefit of regional anesthesia in TCAR, a minimally invasive procedure, because several studies have shown a decrease in morbidity and mortality in patients after CEA, a more invasive procedure with a greater risk of myocardial ischemia. 15 Although there was no mortality difference, Urman et al showed lower rates of perioperative blood loss and pulmonary complications among the regional anesthesia cohort after CEA. 3 Other studies in CEA cohorts have shown a mortality benefit in the regional anesthesia group.…”

“…14 However, recent studies have shown regional anesthesia to be associated with lower morbidity and mortality. [15][16][17] As such, the choice of anesthesia type for carotid artery revascularization continues to be under investigation.…”

Carotid stenosis – basing treatment on individual patients’ needs. Optimal medical therapy alone or accompanied by stenting or endarterectomy

“…As a consequence, due to general anaesthesia, periprocedural risk with CEA might be higher as compared to CAS. In comparison, regional anaesthesia was found to be associated with lower rates of in-hospital strokes or death [36] as well as periprocedural myocardial infarction [37] and therefore could be considered an alternative. However, with CEA, diastolic hypertension has proven to be an independent risk factor of stroke.…”