General Anesthesia for Transcarotid Artery Revascularization Offers Favorable Outcomes in a Symptomatic and High-Risk Population of Patients

Abstract

Transcarotid artery revascularization (TCAR) was developed as a treatment option for patients deemed to be at high risk for traditional surgical revascularization. Previous reports have suggested superior outcomes with avoidance of general anesthesia, although outcomes beyond the perioperative period have not been published. We have adopted TCAR using general anesthesia for all patients, which include those meeting high-risk physiologic and anatomic criteria for TCAR. The purpose of this study was to evaluate outcomes of this strategy with short-term follow-up. This is a retrospective, observational cohort study of all patients undergoing TCAR at a single tertiary care institution from July 2018 to July 2019. Patients undergoing concurrent operations were excluded. All TCAR patients met high-risk profile criteria as required for reimbursement. Data were obtained from detailed chart review. Descriptive statistics were used to assess primary end points of operative and flow reversal time and morbidity, including death, stroke, myocardial infarction, and cranial nerve injury, as well as length of stay and readmissions for comparison to historical controls. Ninety-one patients underwent TCAR, all under general anesthesia. Mean age was 73 ± 9 years, with 39% of patients older than 75 years. There were 66 patients (72.5%) who met high-risk criteria on the basis of their physiologic condition and 37 (40.7%) by anatomic considerations only. Stenosis of 80% to 99% was observed in 71 (78.0%) patients; and overall, 39 (43%) patients were symptomatic. Mean operative and flow reversal times were 55.0 ± 14.3 minutes and 8.8 ± 3.8 minutes, respectively. There were two postoperative strokes (2.2%), both within 30 days. At a mean follow-up of 119 ± 111 days, there were no deaths, myocardial infarction, or cranial nerve injuries. Three patients (3.3%) required short-term vasopressor support and three (3.3%) required prolonged intravenous antihypertensive management. Mean length of stay was 1.5 ± 1.3 days, and unplanned readmission rate was 1.1%. Exclusive use of general anesthesia for TCAR provides expeditious carotid revascularization and minimal short-term morbidity and length of stay in this high-risk population. On short-term follow-up, we observed excellent outcomes including no additional cardiopulmonary morbidity and only one readmission. Additional study in larger, controlled populations is needed to define TCAR patients who may benefit from an anesthetic strategy other than general anesthesia.