Title : A comparison of locoregional versus general anesthesia in patients undergoing carotid endarterectomy: A retrospective single-center study
Abstract:
Objective: Carotid Endarterectomy (CEA) reduces the risk of stroke in patients with asymptomatic and symptomatic extracranial carotid artery stenosis. Modern medical management of extracranial carotid artery stenosis has proven its efficacy and safety; therefore, a low perioperative risk in both anesthesia and surgery is paramount. Outcomes may depend on whether Locoregional Anesthesia (LA) or General Anesthesia (GA) is used. The optimal anesthetic for CEA is controversial. To determine whether the anesthetic method correlated with the outcome of the operation, a retrospective review of 2000 consecutive carotid operations performed over a 10-year period was performed. The aim of our study was to assess the perioperative risks of CEA under locoregional anesthesia compared to those under general anesthesia.
The primary endpoint was the clinical neurological outcome.
The secondary endpoint was the mortality rate.
Design: Retrospective analytical study and prospective clinical data bank.
Patients and methods: The medical records of 2000 consecutive patients who underwent carotid endarterectomy at our institution between June 2013 and June 2023 were prospectively collected and retrospectively reviewed. Operations performed with patients under locoregional anesthesia were compared with those performed with patients under general anesthesia with respect to preoperative risk factors and perioperative complications.
Patients were divided into two groups according to intraoperative anesthetics; locoregional group: 1000 patients versus general anesthetic group: 1000 patients. Ethical approval was obtained from relevant authorities. The requirement for patient consent was waived owing to the retrospective design of this study. Inclusion criteria: Patients with a BMI<35 requiring extracranial carotid endarterectomy, which is considered suitable for either locoregional or general anesthesia. All patients with either symptomatic or asymptomatic extracranial carotid artery stenosis for whom surgery is advised were eligible. There were no upper age limits. Patients following thrombolysis were included. None of the patients underwent mechanical thrombectomy before surgery.
CEA was only performed by a consultant vascular surgeon and anesthetist.
The characteristics of the study groups were strictly standardized, including the exact indications for surgery, diagnostic methods, anesthetic techniques, surgical techniques (indications for and the use of intraluminal shunts, heparin dose, and patching), intraoperative monitoring, postoperative assessment, and antiplatelet therapy. Strict guidelines for anesthetic and surgical management were applied throughout the study.
The following three parameters were measured:
1. Incidence of early and late perioperative strokes
2. Median length of hospital stay
3. Patient Satisfaction Index (PSI)
Confidentiality: All data obtained in this trial is kept and handled in a confidential manner in accordance with applicable laws and regulations.
Results: Perioperative stroke was more common in the GA group (3.5% vs. 0.5%; P<0.001) (Relative risk: Odds Ratio (OR), 1.4; 95% Confidence Interval (CI), 1.214–1.741). Combined death and stroke rates were none in the LA group compared to 0.6% in the GA group (P<0.001). Postoperative episodes of hypertension were more common in the LA group (72.6% vs. 46.4%; P<0.001). Hematomas requiring surgery were more common in the GA group (8.2% vs. 2.1%, P<0.001). The mortality rate was none in the LA group versus 1% in GA group (P<0.001).
Conclusion: CEA can be performed safely and efficiently under locoregional anesthesia. It improves surgical outcomes and leads to better neurological outcomes than general anesthesia.
Risk factor analysis revealed specific risk groups: Men more than women and elderly patient’s more than young patients. Asymptomatic extracranial carotid artery stenosis patients had better outcomes than post-stroke patients. In a retrospective review of a large series of extracranial carotid operations, locoregional anesthesia was shown to be applicable to the vast majority of patients with good clinical outcomes. The versatility and safety of the locoregional anesthetic technique are sufficient for vascular anesthetists and surgeons to include it in the armamentarium of their medical skills.
