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Performing Carotid Artery Stenting under General Anesthesia Revokes the Potential Cardiac Benefits of this Minimally Invasive Procedure
Hanaa Dakour Aridi, MD, Nawar Z. Paracha, MD, Besma Nejim, MBChB, MPH, Satinderjit Locham, MD, Mahmoud B. Malas, MD, MHS, FACS.
Johns Hopkins School of Medicine, Baltimore, MD, USA.

Objective(s): Carotid artery stenting (CAS) was introduced as a minimally invasive alternative to carotid endarterectomy (CEA).CREST have shown lower risk of MI in CAS compared to CEA. However, performing this procedure under general anesthesia (GA) may reverse its minimally-invasive benefits.The aim of this study is to compare the safety profile of CAS-GA to that of CAS under local anesthesia (CAS-LA) and to carotid endarterectomy (CEA-GA).
Methods: A retrospective analysis of the Vascular Quality Initiative (VQI) database 2005-2016 was performed.Primary outcomes included perioperative stroke/death,MI and composite cardiac events (MI, CHF and arrhythmia).Multivariate models were used to evaluate the association between the primary outcomes and anesthesia technique. We further compared the outcomes of GA in a matched cohort of CAS and CEA patients.
Results: Out of 11,132 CAS cases performed, 1,827 (16.6%) were under GA.Patients undergoing CAS-GA were more likely to be younger (67.7vs.69.5 years, p<0.001),females (39.6%vs.35.9%, p=0.003), African Americans (and 7.6%vs.5.1%, p<0.001) and symptomatic (34.5%vs.37.1%, p=0.03) than those having CAS-LA.There was also a significant difference in major comorbidities, degree of ipsilateral and contralateral stenosis, and preoperative medication use between the two groups (Table).CAS-GA had higher in-hospital stroke (4.6%vs.3.5%,p=0.04),30-day stroke/death (8.4%vs.5.2%, p<0.001),MI(1.4%vs.0.7%,p=0.004), CHF(1.5vs.0.7%,p<0.001) and arrhythmia (3.4%vs.2.2%,p=0.003) as compared to CAS-LA.It also required a longer LOS [median (IQR): 2(1-4) vs. 1(1-2),p<0.001),and more frequent treatment for perioperative hypertension (13.5% vs. 8.8%,p<0.001).On multivariate analysis,GA was associated with higher odds of MI [OR: 1.82,95%CI: 1.10-3.03,p=0.02] and composite cardiac events [OR:1.54, 95%CI:1.19 1.99,p=0.001]. However, no difference was noted between the two techniques in 30-day stroke/death rates[OR:1.25,95%CI:0.99-1.58,p=0.05]. In a matched cohort of CAS and CEA patients, MI risk in CAS-GA was similar to CEA-GA(p=0.58).However,CAS-GA carried almost double the risk of stroke/death (p<0.01) and 4.7 folds’ increase in the risk of CHF (p=0.003) compared to CEA.
Conclusions: In addition to the established increase risks of stroke/death with CAS compared to CEA, performing it under GA increases cardiac complications, length of stay and consequently hospitalization costs.Surgeons should refrain from performing CAS under GA especially in medically-high risk patients.
Table 1. Baseline Demographics and Comorbidities of Patients Undergoing Carotid Artery Stenting under Local and General Anesthesia and Patients undergoing Carotid Endarterectomy.

Procedure CAS-LACAS-GACEA-GAp-value
Number of Patients9,172 (13.2)1,827 (2.6)58,608 (84.2)
Age (mean ± SD in years)69.5 (9.9)67.7 (11.9)70.2 (9.4)<0.001
Female Gender3,292 (35.9)723 (39.6)23,353 (39.8)<0.001
Race<0.001
White8,350 (91.1)1,622 (88.8)54,267 (92.7)
Black471 (5.1)138 (7.6)2,475 (4.2)
Others350 (3.8)66 (3.6)1,818 (3.1)
Hispanic or Latino Ethnicity275 (3.0)72 (3.95)1,766 (3.0)<0.001
BMI (mean ± SD in kg/m2)28.4 (6.1)28.2 (6.7)28.7 (86.4)0.91
Pre-Operative Factors
Symptomatic3,406 (37.1)630 (34.5)9,836 (16.8)<0.001
Diabetes3,387 (37.0)594 (32.6)20,511 (35.0)<0.001
Hypertension8,195 (89.4)1,580 (86.6)52,012 (88.8)0.002
Smoking6,992 (76.3)1,363 (74.9)44,383 (75.8)0.34
History of CAD3,082 (33.7)584 (32.0)16,101 (27.5)<0.001
History of coronary revascularization3,618 (40.0)664 (37.0)19,663 (33.9)<0.001
CHF1,376 (15.0)250 (13.7)5,716 (9.8)<0.001
COPD2,336 (25.5)480 (26.4)12,816 (21.9)<0.001
Renal function0.86
Creatinine ≤ 1.8 mg/dl8,488 (94.8)1,691 (95.0)54,281 (94.9)
Creatinine > 1.8 mg/dl466 (5.2)89 (5.0)2,901 (5.1)
ASA Class<0.001
I-II2,020 (24.3)185 (10.3)3,913 (7.3)
III-V6,283 (75.7)1,606 (89.7)50,065 (92.8)
Ipsilateral CAS438 (4.8)107 (5.9)117 (0.3)<0.001
Ipsilateral CEA2,308 (25.2)406 (22.3)1,263 (2.2)<0.001
Pre-op Medications
Aspirin7,965 (86.9)1,444 (79.2)48,602 (83.0)<0.001
Statin7,382 (80.6)1,344 (73.6)46,572 (79.5)<0.001
Beta-blocker5,293 (57.8)978 (53.6)35,438 (60.5)<0.001
ACE Inhibitor3,851 (50.3)780 (48.0)23,456 (51.7)<0.001
P2Y12 Antagonist7,150 (78.0)1,197 (65.6)16,534 (28.2)0.002
Anticoagulation762 (10.0)144 (8.9)4,180 (9.2)0.11
Urgency<0.001
Elective7,643 (83.5)1,251 (68.6)51,192 (87.4)
Urgent1,274 (13.9)374 (20.5)6,978 (11.9)
Emergent238 (2.60)199 (10.9)407 (0.7)
Ipsilateral Stenosis<0.001
<=50%325 (3.6)178 (10.0)914 (1.6)
>50%206 (2.3)69 (3.9)1,492 (2.6)
>60%418 (4.6)114 (6.4)3,217 (5.6)
>70%1,986 (21.8)396 (22.1)15,820 (27.5)
>80%5,925 (65.1)871 (48.7)35,053 (60.9)
Occluded239 (2.6)161 (9.0)1,076 (1.9)
Contralateral Stenosis<0.001
<=50%4,530 (49.8)958 (53.3)29,385 (54.0)
>50%852 (9.4)141 (7.8)7,173 (13.2)
>60%633 (7.0)100 (5.6)5,051 (9.3)
>70%762 (8.4)118 (6.6)5,521 (10.1)
>80%644 (7.1)124 (6.9)4,309 (7.9)
Occluded866 (9.5)179 (10.0)2,966 (5.4)
Unknown804 (8.8)178 (9.90)0
CAS Approach<0.001
Femoral8,969 (98.0)1,411 (77.9)-
Trans-Carotid116 (1.3)383 (21.1)-
Brachial64 (0.7)19 (0.99)-


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