Carotid Endarterectomy: Comparison Between General and Local Anesthesia. Revision of Our Experience With 428 Consecutive Cases

Effect of regional versus general anesthesia on thirty-day outcomes following carotid endarterectomy: a cohort study

BACKGROUND

The effect of regional versus general anesthesia on carotid endarterectomy outcomes is debated. This study assesses the effect of anesthetic technique on major morbidity and mortality and additional secondary endpoints following carotid endarterectomy.

MATERIALS AND METHODS

This was a retrospective propensity-matched-cohort analysis investigating elective carotid endarterectomy patients in the 2015-2019 American College of Surgeons National Surgical Quality Improvement Program ( n =37 204). The primary endpoint was 30-day mortality and major morbidity, defined as stroke, myocardial infarction, or death. Secondary endpoints included minor morbidity, bleeding events, healthcare resource utilization, and length of hospital stay. Univariate, multivariable, and survival analyses were applied.

RESULTS

The 1 : 1 propensity-matched-cohort included 8304 patients (4152 in each group). Regional anesthesia was associated with similar incidences of major morbidity and mortality [odds ratio (OR), 0.81 (95% CI, 0.61-1.09); P = 0.162] and unplanned resource utilization [OR, 0.93 (95% CI, 0.78-1.11); P = 0.443], but lower incidences of minor morbidity [OR, 0.60 (95% CI, 0.44-0.81); P < 0.001] and bleeding events [OR, 0.49 (95% CI, 0.30-0.78); P = 0.002], and a shorter length of hospital stay [1.4 vs. 1.6 days; mean difference, -0.16 days (95% CI, -0.25 to -0.07); P < 0.001]. On multivariable analysis, regional anesthesia remained independently predictive of minor morbidity [adjusted odds ratio (AOR), 0.58 (95% CI, 0.42-0.79); P = 0.001] and bleeding events [AOR, 0.49 (95% CI, 0.30-0.77); P = 0.003]. Significance was maintained on survival analysis for these two endpoints. A mortality benefit was observed on univariate [OR, 0.50 (95% CI, 0.25-1.00); P = 0.045], multivariable [AOR, 0.49 (95% CI, 0.24-0.96); P = 0.043], and survival analysis ( P = 0.045).

CONCLUSIONS

Carotid endarterectomy patients receiving regional anesthesia experience favorable outcomes compared to propensity-matched general anesthesia controls.

General Anesthesia Versus Local Anesthesia in Carotid Endarterectomy: A Systematic Review and Meta-Analysis

OBJECTIVE

The choice of anesthetic technique in carotid endarterectomy (CEA) has been controversial. This study compared the outcomes of general anesthesia (GA) and local anesthesia (LA) in CEA.

DESIGN

Systematic review and meta-analysis of comparative studies.

SETTING

Hospitals.

PARTICIPANTS

Adult patients undergoing CEA with either LA or GA.

INTERVENTIONS

The effects of GA and LA on CEA outcomes were compared.

MEASUREMENTS AND MAIN RESULTS

PubMed, OVID, Scopus, and Embase were searched to June 2018. Thirty-one studies with 152,376 patients were analyzed. A random effect model was used, and heterogeneity was assessed with the I² and chi-square tests. LA was associated with shorter surgical time (weighted mean difference -9.15 min [-15.55 to -2.75]; p = 0.005) and less stroke (odds ratio [OR] 0.76 [0.62-0.92]; p = 0.006), cardiac complications (OR 0.59 [0.47-0.73]; p < 0.00001), and in-hospital mortality (OR 0.72 [0.59-0.90]; p = 0.003). Transient neurologic deficit rates were similar (OR 0.69 [0.46-1.04]; p = 0.07). Heterogeneity was significant for surgical time (I² = 0.99, chi-square = 1,336.04; p < 0.00001), transient neurologic deficit (I² = 0.41, chi-square = 28.81; p = 0.04), and cardiac complications (I² = 0.42, chi-square = 43.32; p = 0.01) but not for stroke (I² = 0.22, chi-square = 30.72; p = 0.16) and mortality (I² = 0.00, chi-square = 21.69; p = 0.65). Randomized controlled trial subgroup analysis was performed, and all the aforementioned variables were not significantly different or heterogenous.

CONCLUSION

The results from this study showed no inferiority of using LA to GA in patients undergoing CEA. Future investigations should be reported more systematically, preferably with randomization or propensity-matched analysis, and thus registries will facilitate investigation of this subject. Anesthetic choice in CEA should be individualized and encouraged where applicable.

Regional anaesthesia techniques for carotid surgery: the state of art

PURPOSE

This review will analyse some aspects of regional anaesthesia (RA) for carotid endarterectomy (CEA), a surgical procedure which requires a strict monitoring of patient's status. RA remains an important tool for the anaesthesiologist. Some debates remain about type and definition of regional anaesthesia, efficacy and safety of the different cervical block techniques, the right dose, concentration and volume of local anaesthetic, the use of adjuvants, the new perspectives: ultrasonography, the future directions.

METHODS

A literature search was performed for journal articles in English language in the PubMed Embase and in The Cochrane Library database, from January 2000 to December 2013. The electronic search strategy contained the following medical subject headings and free text terms: local anaesthesia versus general anaesthesia for endarterectomy, superficial and deep cervical block, complications of cervical nerve block, ultrasound guidance of superficial and deep cervical plexus block.

CONCLUSIONS

The gold standard for RA will be achieved after overcoming a number of limitations by a more extensive use of ultrasonography, by combining general and regional anaesthesia, including conscious anaesthesia, by defining the appropriate volume, concentration and dosage of local agents and by addition of adjuvants.

Carotid endarterectomy—safe and effective in a neurosurgeon's hands: a 25-year single-surgeon experience

OBJECTIVE

Carotid endarterectomy (CEA) is a procedure performed by both vascular surgeons and neurosurgeons in the UK. We present a single neurosurgeon's experience of 728 CEAs over 25 years, performed under both general and local anesthesia, and discuss the results in this context. Our objective was to report on the efficacy of CEA in the hands of a neurosurgeon.

METHODS

Prospective outcome data were collected for all patients who underwent CEA performed by the senior author (A.D.M.) from 1987 to 2011. Data evaluated included patient age, sex, surgical indication, preoperative characteristics, diagnostic modalities used, shunt usage, operative time, any neurological deterioration during or after surgery, and early postoperative problems. Outcome measures used were 30-day death and 30-day disabling stroke. The results were tabulated and analyzed using JMP 8.0.2 (SAS Inc., Cary, NC).

RESULTS

The 30-day death rate was 0.8% and the 30-day disabling stroke rate was 1.7% in our series. The mean operative time was 135 minutes (±38.1), and the mean clamp time was 28.4 minutes (±8.5). In the subset of patients who had the operation performed under local anesthesia (n = 616), the disabling stroke rate was 1.6% and the death rate was 0.6%. In the subset of asymptomatic patients (n = 194), the 30-day death and 30-day disabling stroke rates were each 1%. Postoperative complications were uncommon.

CONCLUSIONS

According to our data, CEA under local anesthesia is safe procedure in the hands of a neurosurgeon and would be recommended according to the clinical presentation and local guidelines.

Outcomes of carotid endarterectomy under general and regional anesthesia from the American College of Surgeons' National Surgical Quality Improvement Program

OBJECTIVE

Despite multiple studies over more than 3 decades, there still is no consensus about the influence of anesthesia type on postoperative outcomes following carotid endarterectomy (CEA). The objective of this study was to investigate whether anesthesia type, either general anesthesia (GA) or regional anesthesia (RA), independently contributes to the risk of postoperative cardiovascular complications or death using the American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP) database.

METHODS

Retrospective analysis of elective cases of CEA from 2005 through 2009 was performed. A propensity score model using 45 covariates, including demographic factors, comorbidities, stroke history, measures of general health, and laboratory values, was used to adjust for bias and to determine the independent influence of anesthesia type on postoperative stroke, myocardial infarction (MI), and death.

RESULTS

Of 26,070 cases listed in the ACS NSQIP database, GA and RA were used in 22,054 (84.6%) and 4016 (15.4%) cases, respectively. Postoperative stroke, MI, and death occurred in 360 (1.63%), 133 (0.6%), and 154 (0.70%) patients of the GA group, respectively, and in 58 (1.44%), 11 (0.27%), and 27 (0.67%) patients of the RA group, respectively. Stratification by propensity score quintile and adjustment for covariates demonstrated GA to be a significant risk factor for postoperative MI with an adjusted odds ratio (OR) and confidence interval (CI) of 2.18 (95% CI, 1.17-4.04), P = .01 in the entire study population. The OR for MI was 5.41 (95% CI, 1.32-22.16; P = .019) in the subgroup of patients with preoperative neurologic symptoms, and 1.44 (95% CI, 0.71-2.90; P = .31) in the subgroup of patients without preoperative neurologic symptoms.

CONCLUSIONS

This analysis of a large, prospectively collected and validated multicenter database indicates that GA for CEA is an independent risk factor for postoperative MI, particularly in patients with preoperative neurologic symptoms.

Comparison Between Local and General Anesthesia for Carotid Endarterectomy: Early and Late Results

Background: The aim of this retrospective study was to compare the results between general and local anesthesia (LA) for carotid endarterectomy (CEA). Methods: Three hundred and twenty-nine patients in whom 365 CEA procedures were performed between January 1990 and September 2001, were included in this study. Results: Operation time, shunt usage rates, hospitalization time ( P < .0001), and permanent stroke rates ( P < .05) were significantly lower in group with LA. For long-term period (121.3 ± 37.45 vs 98.6 ± 28.98 months), no significant difference was observed in these 2 group with respect to restenosis rates, neurological events, and deaths. Conclusions: Despite the lack of significant difference between LA and general anesthesia in terms of restenosis, neurological events, and death in the long-term period; LA is more preferable due its associated advantages including availability of testing the consciousness of the patients by direct contact, reduced use of shunts, shorter hospitalization periods, and less prevalence of permanent stroke in the short-term period.