Anesthetic Type and MI Risk After Carotid Endarterectomy
What is the association between anesthesia type and periprocedural myocardial infarction (MI) among patients receiving general anesthesia (GA) or regional anesthesia (RA) for carotid endarterectomy (CEA) and patients undergoing carotid artery stenting (CAS) in the CREST trial?
This was a post hoc analysis of the CREST (Carotid Revascularization Endarterectomy vs. Stenting Trial) study. CREST was a prospective, randomized, multicenter trial with blinded endpoint adjudication that compared the safety of CEA versus CAS in patients with symptomatic or asymptomatic high-grade extracranial carotid stenosis. The incidence of periprocedural endpoints of protocol MI, protocol MI plus biomarker-positive only MI, stroke, death, and stroke or death were compared between patients undergoing CEA-GA or CEA-RA and those undergoing CAS.
When the combined endpoint of protocol MI and biomarker-positive only MI was analyzed, the patients undergoing CEA-GA had twice the risk of periprocedural MI (odds ratio [OR], 2.01; 95% confidence interval [CI], 1.14-3.54) as those undergoing CAS. Patients who underwent CEA-GA had lower odds of a periprocedural stroke (OR, 0.48; 95% CI, 0.28-0.79; p = 0.005) and stroke or death (OR, 0.46; 95% CI, 0.27-0.76; p = 0.003) than those undergoing CAS.
In the CREST trial, when CEA was performed under GA, the risk of MI was twice that seen in CAS, but when performed under RA, the risk was similar to that with CAS.
This is a valuable study that provides insight on the merits of GA versus RA in patients undergoing CEA. The authors summarize well when they write, ‘Because most CEAs in the United States are performed under GA, if the periprocedural MI rate when the operation is done under RA is equivalent to that of CAS, then transitioning to more frequent use of RA for CEA would optimize the outcomes for patients undergoing carotid revascularization [with surgery] compared with CAS.’
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