Anesthesia Type is Associated with Decreased Cranial Nerve Injury in Carotid Endarterectomy

Abstract

Anesthesia modalities for carotid endarterectomy continue to vary nationally. We evaluated and compared short-term outcomes after carotid endarterectomy with general anesthesia (GA) and regional anesthesia (RA) in both symptomatic and asymptomatic patients. The 2011-2015 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files (PUFs) with merged Vascular Procedure-Targeted PUFs for carotid endarterectomy were queried for patients undergoing carotid endarterectomy. Postoperative complications, mortality, and hospital length of stay in patients undergoing GA or RA were compared. A total of 14,447 patients were evaluated: 12,389 (85.7%) with GA and 2,058 (14.3%) with RA. The use of GA was inversely associated with patients' age (88.0% in patients aged 22-64years vs. 83.4% in patients aged ≥80years, P<0.0001) and with symptomatic presentation (odds ratio [OR]=1.25; 95% confidence interval [CI]: 1.13-1.38). There were no differences between GA and RA for in-hospital mortality, 30-day mortality, or postoperative complications of transient ischemic attack, stroke, bleeding, acute renal failure, or restenosis. However, rates of cranial nerve injury were significantly higher in GA than in RA (2.9% vs. 1.7%, respectively; P<0.002) and confirmed by multivariable analysis (OR=1.68; 95% CI: 1.19-2.39). Total operative time was also longer for GA than for RA (median: 115minutes; Interquartile range (IQR): 89-145 versus median: 93minutes; IQR: 76-119, respectively; P<0.0001). Hospital length of stay was greater in GA than in RA (median: 1day; IQR 1-2 vs. median: 1day; IQR 1-1, respectively; P<0.0001), as were 30-day readmission rates (6.7% vs. 5.4%, respectively; P=0.02). Iatrogenic nerve injury is a feared complication of carotid endarterectomy, especially in elective asymptomatic patients. RA reduces the rate of cranial nerve injury compared with GA. RA is also not inferior to GA for postoperative complications with the benefit of shorter operative times, lengths of hospital stay, and decreased 30-day readmission rates. Consideration should be given to more widespread adoption of this underused anesthesia modality.