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A Multi-institutional Comparison of General versus Regional Anesthesia for Carotid Endarterectomy

Byron J. Faler, MD, Kent DeZee, MD, Gilbert Aidinian, MD, Robyn Macsata, MD, Subodh Arora, MD, Dahlia Plummer, MD, Shukri Khuri, MD, William Henderson, PhD, Tracy Schifftner and Anton Sidawy, MD
Veterans Affairs Medical Center, Washington, DC, William Beaumont Medical Center, El Paso, TX, Harvard Medical School, Boston, MA, University of Colorado Health Sciences Center, Aurora, CO

Objective(s): Carotid endarterectomy (CEA) is one of the most common vascular operations performed on an annual basis to prevent ischemic stroke. As a preventive operation, there must be an acceptably low risk of postoperative morbidity and mortality to have a cumulative patient benefit. The use of regional anesthesia (RA) versus general anesthesia (GA) for CEA has become increasingly popular with the hypothesis that it can decrease the risk of this operation. However, published studies comparing RA and GA report conflicting results about differences in postoperative complications and mortality. In this study, we used the Veterans Affairs’ National Surgical Quality Improvement Program (NSQIP) to compare 30 day outcomes of patients receiving RA versus GA for CEA.
Methods: All patients entered into the NSQIP database from 1 Jan 1996 to 31 Dec 2003 with a primary CPT code of 35301 (CEA) were reviewed. The patients were divided into two groups based on whether they received RA or GA. The preoperative demographics including co-morbidities were compared between the two groups. Multivariate logistic regression with hierarchical modeling was used to compare the incidence of postoperative cardiac, pulmonary, and neurological complications as well as 30 day mortality.
Results: There were 21,153 patients identified (18,466 GA and 2,687 RA). The patients in the GA group were statistically different in that they were older (69 vs. 68, p<0.0001), had a higher incidence of preoperative transient ischemic attack (TIA) or stroke (28.5% vs. 24.7%, p<0.0001), and had a higher incidence of smoking (40.3% vs. 37.1%, p=0.002) and alcohol use (8.9% vs. 7.5%, p=0.02). After controlling for co-morbidities, multivariate logistic regression showed there was no significant difference in 30 day mortality (1.15% RA vs. 1.15% GA, p=0.98), neurological complications (1.6% RA vs. 1.79% GA, p=0.48), or cardiac complications (0.82% RA vs. 1.25% GA, p=0.057) between the two groups. Patients in the GA group, however, were found to have a higher risk of pulmonary complications (1.67% vs. 0.71%, p < 0.001).
Conclusions: Except in patients with high preoperative pulmonary risk, GA and RA can equally be offered as safe anesthetic techniques in patients undergoing CEA.