General versus Non-General Anesthesia for Carotid Endarterectomy: A Prospective Multicenter Registry-based Study on 25,000 Patients

Introduction: Carotid endarterectomy (CEA) is a well-established treatment option for carotid stenosis. The choice between general anesthesia (GA) and non-general anesthesia (non-GA) during CEA remains a subject of debate, with concerns regarding perioperative complications, particularly myocardial infarctions (MIs). This study aimed to evaluate the outcomes associated with GA versus non-GA CEA using a large, nationwide database.

Methods: The National Surgical Quality Improvement Project (NSQIP) database was queried for patients undergoing CEA between 2013 and 2020. Primary outcome measures including surgical outcomes and 30-day postoperative complications were compared between the two anesthesia methods, after 2:1 propensity score matching.

Results: After propensity score matching, a total of 25,356 patients (16,904 in the GA and 8,452 in the non-GA group) were included. Non-GA compared to GA CEA, was associated with significantly shorter operative times (101.9 ± 40.7 vs. 115.8 ± 46.2 minutes, p< 0.001), reduced length of hospital stays (2.3 ± 3.4 vs. 2.5 ± 3.8 days, p< 0.001), and lower rates of 30-day postoperative complications, including MIs (0.8% vs. 1.2%, p=0.003), unplanned intubations (0.8% vs. 1.1%, p=0.016), pneumonia (0.5% vs. 1%, p< 0.001), and urinary tract infections (0.4% vs. 0.7%, p=0.003). These outcomes were notably more pronounced in the younger (≤ 70 years), and high morbidity (ASA 3-5) cohorts.

Conclusion : In this nationwide registry-based study, non-GA CEA was associated with better short-term outcomes in terms of perioperative complications, compared to GA CEA. The findings suggest that non-GA CEA may be a safer alternative, especially in younger patients and those with more comorbidities. Although these results favoring non-GA for CEA are in disagreement with previous trials, they were more representative of the population of patients requiring surgical treatment for carotid stenosis.