Extracranial Carotid Artery Research Articles

“Bead to death,” Fibromuscular Dysplasia Presenting as A Rapidly Enlarging Right Anterior Axillary Mass

Fibromuscular dysplasia (FMD) is a rare non-inflammatory, non-atherosclerotic arterial disease characterized by abnormal cellular proliferation and distorted architecture. It commonly affects the renal and extracranial carotid and vertebral arteries, but nearly all arterial beds may be affected, and multivessel involvement is common. We report a rare case of a 31-year-old Filipino female who presented with a rapidly enlarging right anterior axillary mass. Initial consideration was a bleeding soft tissue sarcoma as seen on chest CT scan, while whole abdominal CT scan with IV contrast revealed incidental findings of multiple aneurysms in the superior mesenteric artery, both renal arteries and right common iliac artery, suggestive of fibromuscular dysplasia. Further vascular imaging studies showed a looped left internal carotid, and a tortuous left brachial artery with beading pattern.

Successful management of mycotic anastomotic pseudoaneurysm of interposition vein graft following a carotid endarterectomy: a case report

BackgroundAnastomotic pseudoaneurysms of interposition vein grafts are a rare entity that requires urgent management to prevent life-threatening complications, such as rupture and thromboembolism, especially when involving the carotid arteries. As these are rare complications and literature is sparse, we believe that this case report can aid the decision-making process in similar circumstances.Case presentationA 49-year-old Ukrainian male patient presented with a false aneurysm of both distal and proximal anastomosis of an interposition vein graft between the common carotid artery and the internal carotid artery, which was previously performed as a bailout procedure after the patient developed a complication of carotid surgery. The patient was successfully treated with extra-anatomical interposition of a vein graft from the subclavian artery to the remnant of extracranial internal carotid artery and en bloc excision of the previous vein graft with the false aneurysms.ConclusionMycotic anastomotic pseudoaneurysms following carotid endarterectomy represent a rare yet serious complication in vascular surgery that requires urgent treatment. While endovascular techniques could represent an alternative option, open surgical repair is still the standard of care for this pathology, offering advantages in preventing postoperative ischemic complications and ensuring optimal long-term outcomes. The open approach provides direct visualization of the pseudoaneurysm. It allows the meticulous debridement of the infected tissues and an accurate reconstruction of the arterial wall with autologous or synthetic grafts. In light of the substantial evidence supporting its superiority, open surgical repair should remain the preferred approach in addressing mycotic anastomotic pseudoaneurysms following carotid endarterectomy. Future research should continue to explore advancements in other surgical techniques and refine treatment strategies to enhance patient outcomes in this challenging clinical scenario.

Application of surgical revascularization technique in giant aneurysm of the extracranial internal carotid artery: technical report.

The purpose of this study is to illustrate the diagnostic and therapeutic value and clinical significance of surgical revascularization in giant aneurysms of the extracranial internal carotid artery. The research team screened a group of cases of giant aneurysms of the extracranial internal carotid artery and analyzed the detailed information of the enrolled patients in terms of their basic clinical characteristics, surgical approaches and clinical prognosis. All patients had a good prognosis, except for one patient who was left with only mild facial nerve palsy (grade II facial paralysis). The results demonstrate that surgical revascularization is effective and safe in the treatment of giant aneurysms of the extracranial internal carotid artery. The significant conclusion of this study is to provide an ideal alternative treatment for the treatment of giant aneurysms of the extracranial internal carotid artery. The surgical revascularization technique is a powerful tool for vascular neurosurgeons in the management of complex cerebrovascular diseases when traditional surgical clipping or endovascular interventions encounter bottlenecks.

Extracranial internal carotid artery aneurysm: Surgical approach to a rare entity.

Extracranial internal carotid artery aneurysms are rare entities that arise within the carotid triangle. Although rare, they are clinically significant due to the risk of neurologic thromboembolic events, compression of cranial nerves and vasculature, rupture, and ischemia. Surgery is the gold-standard treatment for symptomatic patients of all ages with extracranial internal carotid artery aneurysm. A 26-year-old female patient was admitted to our institution with complaints of left auricular pain, hoarseness, and uncontrollable hypertension. She had a pulsatile mass located at the left cervical region. After diagnosing the extracranial internal carotid artery aneurysm, it was decided that surgery was necessary to relieve the patient's discomfort and prevent possible complications from the aneurysm in the left carotid artery. In the operation, the aneurysmatic segment was resected and sent for histopathological evaluation. Saphenous vein graft was interposed as end to end anastomosis to the proximal and distal healthy segments of the internal carotid artery. This case report highlights the surgical management of a 26-year-old female patient who presented to our institution with complaints of left auricular pain, hoarseness, uncontrolled hypertension, and a pulsatile mass localized at the left cervical region and diagnosed extracranial internal carotid artery aneurysm.

Idiopathic extracranial internal carotid artery vasospasm: case report and systematic review.

Idiopathic extracranial internal carotid artery vasospasm (IEICAV) is characterized by spontaneous, recurrent, and reversible vasoconstriction of the cervical internal carotid artery (ICA). The etiology remains elusive, and no effective treatment has been established. The present study presents a case of recurrent IEICAV with migraine-like symptoms and conduct a systematic review on IEICAV. A retrospective analysis was conducted on a case involving medical history, radiological data, treatment, and outcomes. A systematic review of published IEICAV cases was conducted through database searching in PubMed, Embase, and Web of Science from inception until May 2024. A 22-year-old female with recurrent headaches, blurred vision, and aphasia was diagnosed with bilateral IEICAV through angiography. Magnetic resonance imaging demonstrated a novel cerebral infarction during a prolonged episode. Treatment with topiramate successfully controlled recurrence in a 5-month follow-up. The systematic review included 36 IEICAV cases reported by literature. Bilateral involvement of extracranial ICAs was observed in 25 (69.4%) cases. Cerebral infarction was identified in 31 (88.9%) cases. Despite various treatment attempts including vasodilators, antiplatelet, anticoagulants, glucocorticoids, and other medical or surgical intervention, the recurrent rate increased in 5 (13.9%) cases, decreased in 10 (27.8%) cases, and remained unchanged in 4 (11.1%) cases. The elusive mechanism of IEICAV brings great difficulty into managing recurrence. Preventing IEICAV-related infarction related to secondary factors like hypoperfusion may be crucial for maintaining life quality. Further research is essential for advancing treatment strategies and a case-by-case approach is needed in identifying and eliminating possible triggers for vasospastic episodes.

Long-Term Clinical Outcomes After Cerebral Revascularization in Moyamoya Disease With Extracranial Internal Carotid Artery Occlusion

ObjectiveThe aim of this study is to evaluate the efficacy of cerebral revascularization for Moyamoya disease (MMD) with extra-cranial internal carotid artery occlusion (ICAO). MethodsThis study retrospectively analyzed 37 patients diagnosed with MMD with extra-cranial ICAO who underwent cerebral revascularization surgery. We conducted propensity score matching for MMD patients without extra-cranial ICAO from database of 932 MMD patients. Outcome data, recurrent strokes and modified Rankin Scale (mRS) were collected during follow-up. ResultsA total of 37 MMD patients with extra-cranial ICAO were included in the study. The average follow-up time of MMD patients with extra-cranial ICAO included in the study was 74 months. During the follow-up period, there were 15 hemispheres recurred stroke events. All hemispheres underwent surgery, and the follow-up mRS score was significantly reduced (P <0.001). Kaplan-Meier analysis showed no significant statistical difference in stroke events between the indirect bypass (IB), direct bypass (DB), and combined bypass (CB) groups (P = 0.131). After propensity matching, 48 hemispheres of MMD patients without extra-cranial ICAO were identified from a review of 932 MMD patients. There was no significant statistical difference in stroke events between the MMD patients with extra-cranial ICAO group and the MMD group (P = 0.271). ConclusionsCerebral revascularization can prevent recurrent ischemic and hemorrhagic stroke events for MMD patients with extra-cranial ICAO. There was no difference on long-term clinical outcomes after CB, DB, and IB surgery. The cerebral revascularization has similar effect on the MMD patients with extra-cranial ICAO and MMD patients without.

Advancements in Endovascular Treatment of Extracranial Carotid Artery Aneurysms

Traditionally, extracranial carotid artery aneurysms or pseudoaneurysms (ECCAs) have been managed through open surgical repair. Recent literature highlights the increasing success of endovascular techniques in treating ECCAs. Our study explores our center's experience with endovascular management of ECCAs, including the innovative use of Transcarotid Artery Revascularization (TCAR) at a tertiary care center. We performed a retrospective analysis of patients with ECCAs who underwent endovascular intervention at a single institution. We examined our database from the period of 2010 to 2024. Our treatment modalities have expanded to include covered stenting, stent-assisted coil embolization, braided stents, overlapping closed-cell stents, and most recently Transcarotid Artery Revascularization (TCAR). There were 29 extracranial carotid artery aneurysms in 27 patients treated with various endovascular modalities. The average age was 67.6 years, with 17 (63.0%) males and 10 (37.0%) females. 8 (29.6%) patients had prior ipsilateral carotid intervention. 9 (31.0%) aneurysms were symptomatic. The most common etiology was idiopathic, with 16 (55.2%) aneurysms being spontaneous. Treatment modalities included: 2 (6.9%) treated with covered stents, 2 (6.9%) with stent-assisted embolization, 3 (10.3%) with flow-diverting braided stents, 3 (10.3%) with embolization or ligation alone, 17 (58.6%) with overlapping bare metal stents via femoral or radial access, and 2 (6.9%) with overlapping bare metal stents via TCAR. Technical success was achieved in all patients. The mean follow-up duration was 236 days (range: 2 to 3039 days). No perioperative or post-operative complications occurred, including no neurological deficits or embolic events. All patients were discharged on post-operative day 1 or 2. All 29 (100%) stents maintained vessel patency on follow-up imaging, and exclusion of ECCAs was confirmed on post-procedure surveillance imaging. Our study highlights that endovascular therapy is effective in managing ECCAs, with high patency rates and a favorable procedural safety profile.

Nonlinear biomechanical behaviour of extracranial carotid artery aneurysms in the framework of Windkessel effect via FSI technique

Extracranial carotid artery aneurysms (ECCA) lead to rupture and neurologic symptoms from embolisation, with potentially fatal outcomes. Investigating the biomechanical behaviour of EECA with blood flow dynamics is crucial for identifying regions more susceptible to rupture. A coupled three-dimensional (3D) Windkessel-framework and hyperelastic fluid-structure interaction (FSI) analysis of ECCAs with patient-specific geometries, was developed in this paper with a particular focus on hemodynamic parameters and the arterial wall's biomechanical response. The blood flow has been modelled as non-Newtonian, pulsatile, and turbulent. The biomechanical characteristics of the aneurysm and artery are characterised employing a 5-parameter Mooney-Rivlin hyperelasticity model. The Windkessel effect is also considered to efficiently simulate pressure profile of the outlets and to capture the dynamic changes over the cardiac cycle. The study found the aneurysm carotid artery exhibited the high levels of pressure, wall shear stress (WSS), oscillatory shear index (OSI), and relative residence time (RRT) compared to the healthy one. The deformation of the arterial wall and the corresponding von Mises (VM) stress were found significantly increased in aneurysm cases, in comparison to that of no aneurysm cases, which strongly correlated with the hemodynamic characteristics of the blood flow and the geometric features of the aneurysms. This escalation would intensify the risk of aneurysm wall rupture. These findings have critical implications for enhancing treatment strategies for patients with extracranial aneurysms.

Anatomical variations of origin of the internal carotid artery: Report of two cases and systematic review of the literature.

Anatomical variations of origin of the internal carotid artery (ICA) are very uncommon and may pose a diagnostic and therapeutic challenge. We report a case of direct origin of the right ICA from the innominate artery (aplasia of common carotid artery) and a case of duplication of right ICA in healthy patients who performed duplex ultrasound (DUS) for primary cardiovascular prevention screening. In both cases, the ultrasound scan was performed both in a transverse plane and on the longitudinal axis, and in one of the two cases, a computed tomography angiography was performed to confirm the diagnosis. A review of the current literature about anatomical variations of origin of carotid arteries was also performed. The most frequent congenital anomaly is represented by the aplasia of the CCA, followed by the agenesis and by the duplication of the ICA. In most cases, the anomaly is discovered occasionally and symptoms are aspecific. Diagnosis is usually confirmed through a multimodality imaging approach, including DUS of extracranial carotid arteries, magnetic resonance imaging (MRI), and computed tomographic angiography. In most cases, treatment was conservative, with pharmacological therapy aimed at the symptoms. The recognition of such variations is mandatory, particularly when the patient needs a surgical treatment that may involve the vessel with the anatomical variations.

Covered stent deployment for a recurrent cervical internal carotid artery aneurysm referencing angioscopy: illustrative case.

Extracranial carotid artery aneurysms (ECAAs) are rare, and treatment guidelines are lacking. Few reports on endovascular treatments performed for ECAAs exist. A 73-year-old woman with a left giant cervical internal carotid artery aneurysm was treated with overlapping closed-cell stents. The aneurysm regrew 1 year after the treatment, and then a covered stent was deployed. Angioscopy was performed to confirm neointimal development to determine the appropriate stent position before the retreatment, and it revealed that the stent struts were embedded in thick neointima for the most part but that the neointima was thin around the aneurysm neck. Multiple holes connecting to the aneurysm were observed between the stent struts. A covered stent overlapped inside the closed-cell stents, and blood flow into the aneurysm completely disappeared. When deploying the covered stent for recurrent aneurysms, angioscopy is useful for confirming neointimal development and determining the appropriate stent length and position. Angioscopic observations suggest that using stents with a higher mesh density and smaller pore size can reduce the neck hole size of the aneurysm and may achieve complete occlusion of the aneurysm. https://thejns.org/doi/10.3171/CASE24383.

Arteriosclerotic Calcification and Atrial Fibrillation in the General Population: The Rotterdam Study

Limited population-based data on the gender differences and association between arteriosclerotic calcification at different sites and atrial fibrillation (AF) exist. We aimed to investigate the (gender-specific) associations between arteriosclerotic calcification at different sites with the risk of AF in the general population. Arteriosclerotic calcification was quantified using computed tomography examinations between 2003 and 2006 in 2,259 participants free of AF from the population-based Rotterdam Study. Cox proportional hazards models, adjusted for cardiovascular risk factors, were used to assess the associations of volumes of coronary artery calcification (CAC), aortic arch calcification (AAC), extracranial and intracranial carotid arteries, vertebrobasilar arteries, and the aortic valve with incident AF. During a median follow-up of 8.6 years, 182 incident AF cases occurred. A larger CAC was associated with incident AF (hazard ratio [HR], 95% confidence interval [CI] 1.25 1.09 to 1.44, p = 0.0019). The gender-stratified analyses showed that larger CAC in men (HR 1.43, 95% CI 1.10 to 1.86, p = 0.0068) and larger AAC in women were associated with incident AF (HR1.44, 95% CI 1.04 to 2.01, p = 0.0299). In conclusion, CAC in the general population, especially in men, and AAC in women were significantly associated with new-onset AF. Our findings imply that interventions to lower arteriosclerotic calcification, particularly, CAC, carry potential for the prevention of AF in the general population, especially in men.

The Dual-layer CGuard Stent Is Safe and Effective in Emergent Carotid Artery Stenting and in Tandem Occlusions: aMulti-centric Study.

Dual-layer stents have fallen into disrepute after several studies reported high rates of in-stent occlusions in acute stroke treatments. The CGuard stent is anew-generation hybrid dual-layer stent that has been designed to provide less thrombogenicity and to prevent peri- and postinterventional emboli. The aim of the study is to evaluate the safety and efficacy of the CGuard stent for the acute treatment of occlusion or high-grade stenosis of the extracranial internal carotid artery (ICA) in patients with acute ischemic stroke (AIS) with and without concomitant intracranial large vessel occlusion (LVO). All patients who underwent emergent carotid artery stenting (CAS) with the CGuard stent were identified and analyzed from the stroke registries from four tertiary German stroke centers. Clinical, procedural, and imaging data were evaluated. Stent patency within 72 h, intracranial hemorrhage, and modified Rankin score (mRS) at discharge were the safety and efficacy end points. Overall, ninety-six patients were included (mean age70.2 ± 11.8, 66males (68.8%), median NIHSS score at admission 11 (7-17), IVlysis: n = 44 (45.8%)). Stent placement was successful in all patients. Eighty-three (86.4%) patients had tandem occlusions. In-stent occlusion occurred in 5patients (5.2%) and 3patients developed early in-stent stenosis (3.1%). Median mRS at discharge was 2 (1-4). In this multicenter study, the use of the dual-layer CGuard stent for emergent CAS, particularly in tandem occlusions, was safe and resulted in low rates of in-stent occlusions.

Timing of Intervention in Symptomatic Carotid Artery Stenosis

Symptomatic carotid artery stenosis is defined as an acute neurologic deficit (transient ischemic attack or stroke) occurring in the last six months that is ipsilateral to an extracranial carotid artery with at least 50% stenosis. Previous studies have identified the benefit of surgical intervention on symptomatic carotid stenosis, but the ideal timing is less clear. The timing of intervention must balance the risk of perioperative stroke and death (higher during the hyperacute period within 48 hours) and the risk of recurrent stroke while waiting to intervene, particularly if delayed beyond 14 days. Several factors such as acuity of neurological deficit, degree of stenosis or contralateral occlusion, and other comorbidities, may contribute to the risk of perioperative stroke or death when intervening within the acute period. The Society for Vascular Surgery recommends carotid endarterectomy as the intervention for symptomatic carotid artery stenosis, but recent studies have shown that transcarotid revascularization may also have similar outcomes.

Giant cell arteritis as a cause of extracranial internal carotid artery aneurysm: a case report

BackgroundThis report presents the management of patient with extracranial internal carotid artery pseudoaneurysm due to giant cell arteritis.Case presentationLeft internal carotid artery pseudoaneurysm was diagnosed in a 57-year-old Ukrainian woman, which became a direct indication for surgical treatment involving aneurysm resection and internal carotid artery reimplantation. The used reconstruction technique with oblique cutting of internal carotid artery, aneurysm resection, ellipse-form anastomosis formation, and distal intima fixation prevents the dissection, restenosis, and aneurysm of anastomosis in the long-term postoperative period. Histopathological examination revealed the giant cell arteritis of the internal carotid artery.ConclusionThis case emphasizes the importance of open surgical treatment of extracranial carotid artery aneurysms, which allows to perform optimal carotid artery reconstruction and also define the rare etiology of disease.

Ultrasound Evaluation of Extra Cranial Carotid Arteries and Its Correlation with Different Risk Factors of Atherosclerosis

Ultrasound Evaluation of Extra Cranial Carotid Arteries and Its Correlation with Different Risk Factors of Atherosclerosis

Prevalence of RNF213 rs112735431 Genetic Polymorphism in Non-Cardioembolic Ischemic Cerebrovascular Disease: A Cross-Sectional Study in Thai Patients

Introduction: Moyamoya disease (MMD) and non-MMD intracranial cerebral artery stenosis (ICAS) have been linked to the RNF213 rs112735431 gene in Korean and Japanese populations. This cross-sectional study investigates the prevalence of the RNF213 rs112735431 gene in non-cardioembolic ischemic stroke (NCIS) among Thai patients. Methods: A cross-sectional investigation was conducted on patients aged 18 years or older admitted to King Chulalongkorn Memorial Hospital between June 2015 and March 2016 with acute NCIS. ICAS and extracranial carotid artery stenosis (ECAS) were assessed through computer tomography angiography or magnetic resonance angiography. Blood samples were collected, and Sanger sequencing was performed. Results: Among 234 acute NCIS cases, 113 exhibited ICAS, 12 had ECAS, 20 had both, and 89 had neither. The RNF213 rs112735431 gene variant was detected in 2 patients, both heterozygous A/G. The frequency of the RNF213 rs112735431 variant was 0.9% (2/234; 95% CI: 0–2.1%) in acute NCIS patients and 1.8% (2/113; 95% CI: 0–4.2%) in ICAS. All individuals with the RNF213 variant were males with hypertension, diabetes mellitus, dyslipidemia, and ICAS, without a family history of ischemic stroke. Conclusion: This study reveals that the RNF213 rs112735431 gene variant is uncommon among Thai NCIS patients, suggesting a discrepancy in the prevalence of this genetic variation between Thai and other Eastern Asian populations.

Improved cognition and preserved hippocampal fractional anisotropy in subjects undergoing carotid endarterectomy “CEA preserves cognition & hippocampal structure”

ObjectivesA growing body of data indicates that extracranial carotid artery disease (ECAD) can contribute to cognitive impairment. However, there have been mixed reports regarding the benefit of carotid endarterectomy (CEA) as it relates to preserving cognitive function. In this work, diffusion magnetic resonance imaging (dMRI) and neurocognitive testing are used to provide insight into structural and functional brain changes that occur in subjects with significant carotid artery stenosis, as well as changes that occur in response to CEA. Materials and MethodsThe study design was a prospective, non-randomized, controlled study that enrolled patients with asymptomatic carotid stenosis. Thirteen subjects had severe ECAD (≥70% stenosis in at least one carotid artery) and were scheduled to undergo surgery. Thirteen had asymptomatic ECAD with <70% stenosis, therefore not requiring surgery. All subjects underwent neurocognitive testing using the Montreal Cognitive Assessment test (MoCA) and high angular resolution, multi-shell diffusion magnetic resonance imaging (dMRI) of the brain at baseline and at four-six months follow-up. Changes in MoCA scores as well as in Fractional anisotropy (FA) along the hippocampus were compared at baseline and follow-up. ResultsAt baseline, FA was significantly lower along the ipsilateral hippocampus in subjects with severe ECAD compared to subjects without severe ECAD. MoCA scores were lower in these individuals, but this did not reach statistical significance. At follow-up, MoCA scores increased significantly in subjects who underwent CEA and remained statistically equal in control subjects that did not have CEA. FA remained unchanged in the CEA group and decreased in the control group. ConclusionsThis study suggests that CEA improves cognition and preserves hippocampal white matter structure compared to control subjects not undergoing CEA.

Assessments of arterial and venous phase radiodensity does not improve carotid near-occlusion diagnostics

The hypothesis of this study was that evaluation of radiodensity assessment beyond a carotid stenosis in arterial and/or venous phase can be used to separate near-occlusion and conventional ≥ 50% stenosis. We prospectively included participants with ≥ 50% carotid stenosis with inclusion preference for cases with extracranial internal carotid artery (ICA) asymmetry. All participants were examined with a research biphasic computed tomography angiography (CTA) protocol (arterial and venous phase). Reference diagnosis was set by interpretation on CTA and radiodensity difference between ipsilateral and contralateral ICA (c-corrected) or vertebral (v-corrected) was compared. We included 93 participants, 62 with near-occlusion and 31 with conventional ≥ 50% stenosis. Just beyond the stenosis, median c-corrected radiodensity was − 20 Hounsfield units (HU) among near-occlusions and − 1 HU among conventional ≥ 50% stenoses (p < 0.001) in the arterial phase. For the venous phase, these findings were + 17 HU and + 3 HU (p = 0.007). Similar group differences were seen for v-correction. No parameter had good diagnostic performance, area under the curve ≤ 0.82. With specificity set at ≥ 95%, detected near-occlusions were foremost those with large side-to-side differences in distal ICA-diameter. Carotid near-occlusions can have reduced radiodensity beyond the stenosis in arterial phases and increased radiodensity in venous phases compared to a reference artery—which was not clearly seen for conventional stenoses. However, these radiodensity findings are best seen in near-occlusion cases that are not diagnostically challenging, while they work poorly as additional diagnostic aids.

Invasive treatment for extracranial carotid artery aneurysm: a single-center case series and literature review

BackgroundExtracranial carotid artery aneurysm (ECAA) is a rare peripheral arterial disease. The main treatment strategies include conservative treatment, open surgery, endovascular treatment, and hybrid techniques, and there is no expert consensus or guidelines, with only a few case reports.MethodThis article reviewed 10 cases diagnosed with "extracranial carotid artery aneurysm" and received invasive treatment from January 2013 to July 2023 in our medical center.ResultsThere were 10 patients with ECAA admitted to our center, including seven cases of true aneurysms, two cases of pseudoaneurysms, and one case of dissecting aneurysm. There were 3 females and 7 males aged between 24–61 years. Based on the characteristics of ECAA, we designed the individualized procedure including open surgery, endovascular treatment, and hybrid treatment. Procedures were technically successful for all patients, and none of them had any adverse events during the follow-up period except for one patient who developed cerebral hemorrhage on the third postoperative day and recovered after cerebral puncture and drainage.ConclusionThe current invasive treatments for ECAA mainly include open surgery, endovascular treatment, and hybrid treatment, and they all appear to be safe and effective.

Association Between Hospital Policy on Local Versus General Anesthesia, and Outcomes of Carotid Endarterectomy

BACKGROUND Carotid endarterectomy (CEA) is an established procedure for the treatment of extracranial internal carotid artery stenosis. However, the type of anesthesia during elective CEA is still under debate. This study analyzes the association between the hospital policy on local anesthesia (LA) versus general anesthesia, and the outcome of elective CEA in German hospitals. METHODS This retrospective analysis is based on the nationwide German statutory carotid quality assurance database for the years 2012 to 2016. Research was funded by Germany's Federal Joint Committee Innovation Fund (funding reference number 01VSF19016). Emergency CEA and carotid stenting procedures were excluded from the analysis. A total of 119 800 patients remained in the analysis. Hospitals were classified on a yearly basis as routine general anesthesia (&lt;10% LA), selective LA (10%–90% LA), or routine LA centers (&gt;90% LA). The primary outcome event was the combined in‐hospital rate of stroke or death. Secondary outcome events were in‐hospital stroke, major stroke or death, death, myocardial infarction, and major adverse cardiovascular events. Univariate and multivariable regression analyses were performed to analyze associations between the primary outcome event and the hospital policy on LA versus general anesthesia as well as clinical or procedural variables. RESULTS Patient characteristics did not differ significantly between the groups (age, degree of stenosis, and rate of symptomatic patients). Raw primary outcome event rates were 1.9%, 2.1%, and 1.6% in routine general anesthesia, selective LA, and routine LA centers, respectively. Multivariable analysis revealed a significant lower rate of the primary outcome event for CEA operated under LA (adjusted odds ratio, 0.47 [95% CI, 0.33–0.67]; P &lt;0.001). Stratified multivariable analysis revealed that the beneficial effect of LA was only present in routine LA centers. CONCLUSION LA is associated with a lower risk of in‐hospital stroke or death after CEA in centers that use LA routinely.