In the Journals

Carotid endarterectomy with general anesthesia confers greater periprocedural MI risk vs. stenting

Patients undergoing carotid endarterectomy with regional anesthesia appear to have a comparable risk for periprocedural MI compared with those who undergo carotid artery stenting. However, carotid endarterectomy with general anesthesia doubled the risk for MI compared with carotid artery stenting, according to a new analysis of the CREST trial.

For the post hoc analysis, researchers evaluated patients who underwent carotid endarterectomy (CEA) and those who underwent carotid artery stenting (CAS). CREST is a prospective, randomized, multicenter trial that analyzed the safety of CEA vs. CAS in patients with symptomatic or asymptomatic high-grade extracranial stenosis.

The present analysis included 1,149 patients who underwent CEA and 1,123 who underwent CAS.

The researchers stratified CEA patients by anesthetic type (general vs. regional) and compared the two groups in terms of the following periprocedural endpoints: protocol MI, protocol MI plus biomarker-positive-only MI, stroke, death, and stroke or death. Protocol MI was characterized as chest pain or change in ECG plus biomarker indication of MI. Total MI was defined as protocol MI in addition to MI identified by biomarker-positivity only. The researchers compared the incidence of both protocol and total MI in patients treated with CEA under general anesthesia and regional anesthesia with patients undergoing CAS.

Of the 1,149 CEA patients for whom anesthesia type was known, local/regional anesthesia was used in 111 and general anesthesia was used in 1,038.

The baseline characteristics comparable across the groups, with the exception of symptomatic carotid stenosis, which was least prevalent among CEA regional anesthesia patients (P = .03), procedural hypotension, which was higher in the CAS group (P < .001), and procedural hypertension, which was more prevalent in the surgical group (P < .001).

Fifty-six MIs were detected; of these, 34% were detected by biomarker elevations alone. There were no protocol MIs and two biomarker-positive-only MIs among the 111 patients in the CEA regional anesthesia group, equaling an overall incidence of 1.8%. This was similar to the 1.7% overall incidence rate in CAS patients. Conversely, of the 1,038 patients in the CEA general anesthesia group, combined incidence of protocol and biomarker-positive-only MIs was higher (3.4%; P = .04) vs. CAS patients, equaling twice the risk of both protocol and biomarker-positive-only MI (OR = 2.01; 95% CI, 1.14-3.54).

Eight patients died: none in the CEA regional anesthesia group, two in the CEA general anesthesia group and six in the CEA general anesthesia group. The CEA regional anesthesia group had one stroke (0.9%) vs. 22 (2.1%) among the CEA general anesthesia patients, and 48 (4.3%) in CAS patients (P = .006).

In a direct comparison of the MI incidence between the CEA regional anesthesia and CEA general anesthesia groups, no statistical difference was seen, owing to the low event rate in the CEA regional anesthesia group (OR = 0.53; 95% CI, 0.13-2.25), according to the researchers. Compared with CAS, patients who underwent CEA with general anesthesia had lower odds of periprocedural stroke (OR = 0.48; 95% CI, 0.28-0.79) and stroke or death (OR = 0.46; 95% CI, 0.27-0.76). However, these odds were not significantly different from those treated with CEA regional anesthesia, according to the researchers.

“In CREST, when CEA was performed under [general anesthesia] the risk of MI was twice that seen in CAS, but when performed under [regional anesthesia], the risk was similar to CAS,” the researchers wrote. “These findings suggest that surgeons performing CEA should seriously consider use of [regional anesthesia] to provide optimal outcomes for their patients.” – by Jennifer Byrne

Disclosure: Abbott Vascular proved supplemental funding for this study. The researchers report no relevant financial disclosures.

Patients undergoing carotid endarterectomy with regional anesthesia appear to have a comparable risk for periprocedural MI compared with those who undergo carotid artery stenting. However, carotid endarterectomy with general anesthesia doubled the risk for MI compared with carotid artery stenting, according to a new analysis of the CREST trial.

For the post hoc analysis, researchers evaluated patients who underwent carotid endarterectomy (CEA) and those who underwent carotid artery stenting (CAS). CREST is a prospective, randomized, multicenter trial that analyzed the safety of CEA vs. CAS in patients with symptomatic or asymptomatic high-grade extracranial stenosis.

The present analysis included 1,149 patients who underwent CEA and 1,123 who underwent CAS.

The researchers stratified CEA patients by anesthetic type (general vs. regional) and compared the two groups in terms of the following periprocedural endpoints: protocol MI, protocol MI plus biomarker-positive-only MI, stroke, death, and stroke or death. Protocol MI was characterized as chest pain or change in ECG plus biomarker indication of MI. Total MI was defined as protocol MI in addition to MI identified by biomarker-positivity only. The researchers compared the incidence of both protocol and total MI in patients treated with CEA under general anesthesia and regional anesthesia with patients undergoing CAS.

Of the 1,149 CEA patients for whom anesthesia type was known, local/regional anesthesia was used in 111 and general anesthesia was used in 1,038.

The baseline characteristics comparable across the groups, with the exception of symptomatic carotid stenosis, which was least prevalent among CEA regional anesthesia patients (P = .03), procedural hypotension, which was higher in the CAS group (P < .001), and procedural hypertension, which was more prevalent in the surgical group (P < .001).

Fifty-six MIs were detected; of these, 34% were detected by biomarker elevations alone. There were no protocol MIs and two biomarker-positive-only MIs among the 111 patients in the CEA regional anesthesia group, equaling an overall incidence of 1.8%. This was similar to the 1.7% overall incidence rate in CAS patients. Conversely, of the 1,038 patients in the CEA general anesthesia group, combined incidence of protocol and biomarker-positive-only MIs was higher (3.4%; P = .04) vs. CAS patients, equaling twice the risk of both protocol and biomarker-positive-only MI (OR = 2.01; 95% CI, 1.14-3.54).

Eight patients died: none in the CEA regional anesthesia group, two in the CEA general anesthesia group and six in the CEA general anesthesia group. The CEA regional anesthesia group had one stroke (0.9%) vs. 22 (2.1%) among the CEA general anesthesia patients, and 48 (4.3%) in CAS patients (P = .006).

In a direct comparison of the MI incidence between the CEA regional anesthesia and CEA general anesthesia groups, no statistical difference was seen, owing to the low event rate in the CEA regional anesthesia group (OR = 0.53; 95% CI, 0.13-2.25), according to the researchers. Compared with CAS, patients who underwent CEA with general anesthesia had lower odds of periprocedural stroke (OR = 0.48; 95% CI, 0.28-0.79) and stroke or death (OR = 0.46; 95% CI, 0.27-0.76). However, these odds were not significantly different from those treated with CEA regional anesthesia, according to the researchers.

“In CREST, when CEA was performed under [general anesthesia] the risk of MI was twice that seen in CAS, but when performed under [regional anesthesia], the risk was similar to CAS,” the researchers wrote. “These findings suggest that surgeons performing CEA should seriously consider use of [regional anesthesia] to provide optimal outcomes for their patients.” – by Jennifer Byrne

Disclosure: Abbott Vascular proved supplemental funding for this study. The researchers report no relevant financial disclosures.

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