Carotid endarterectomy under local and/or regional anesthesia has less risk of myocardial infarction compared to general anesthesia: An analysis of national surgical quality improvement program database

Abstract

Multiple studies have evaluated the effect of anesthesia type on carotid endarterectomy with inconsistent results. Our study compared 30-day postoperative myocardial infarction, stroke, and mortality between carotid endarterectomy under local or regional anesthesia and carotid endarterectomy under general anesthesia utilizing National Surgical Quality Improvement Program database. All patients listed in National Surgical Quality Improvement Program database that underwent carotid endarterectomy under general anesthesia and local or regional anesthesia from 2005 to 2011 were included with the exception of patients undergoing simultaneous carotid endarterectomy and coronary artery bypass grafting. The data revealed substantial differences between the two groups compared, and these were adjusted using multiple logistic regression. Postoperative myocardial infarction, stroke, and death at 30 days were compared between the two groups. A total of 42,265 carotid endarterectomy cases were included. A total of 37,502 (88.7%) were performed under general anesthesia and 4763 (11.3%) under local or regional anesthesia. Carotid endarterectomy under local or regional anesthesia had a significantly decreased risk of 30-day postoperative myocardial infarction when compared to carotid endarterectomy under general anesthesia (0.4% vs 0.86%, p = 0.012). No statistically significant differences were found in postoperative stroke or mortality. Carotid endarterectomy under local or regional anesthesia carries a decreased risk of postoperative myocardial infarction when compared to carotid endarterectomy under general anesthesia. Therefore, patients at risk of postoperative myocardial infarction undergoing carotid endarterectomy, consideration of local or regional anesthesia may reduce that risk.

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

“…This difference was largely a result of the increased incidence of MI in the subset of patients with preoperative neurologic symptoms. Kfoury, et al 21 analyzed the results of 42,265 CEA, 11.3% done under RA, from the same database and also found that the incidence of MI was significantly higher in the GA group, (.86% vs .4%, P=.012).…”

“…Advocates of CAS have contended that this adverse impact on mortality in CEA patients is equally, if not more important than the reduced incidence of periprocedural strokes, most of which are minor. Since the vast majority of CEA in the United States are performed under GA, 19,21 if the periprocedural MI rate when the operation is done under RA is equivalent to that of CAS, then transitioning to more frequent use of RA for CEA would optimize the outcomes for patients undergoing carotid revascularization when compared to CAS. Barriers to this transition are vascular surgeons and anesthesiologists who are comfortable with their present approach, achieve excellent results and thus have little impetus to change.…”

“…Several studies have shown equivalent rates of periprocedural MI regardless of anesthetic technique while others have shown a trend or significant difference favoring one technique over the other. 12,15-21 This issue is important not only because of the immediate consequences of a periprocedural MI but also because several studies have demonstrated a survival disadvantage in patients suffering these periprocedural events, even when the event itself consists of only a small elevation in cardiac enzymes. 22-28 Whether this survival difference is due to the consequences of the periprocedural cardiac ischemic event itself or is simply a marker identifying a patient with more advanced or unstable coronary artery disease is not entirely clear.…”

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

“…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. 15 Evidence for a link between anesthetic technique and postoperative MI can be found on both sides of the equation, and this study does not offer additional evidence that RA is protective against postoperative MI.…”

“…[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.…”