Impact of the type of anesthesia on adverse events during transcarotid artery revascularization

Brajesh K Lal; Minerva Mayorga-Carlin; Shalini Sahoo; Richard Cambria; Joseph D Raffetto; Warren Gasper; Mila Ju; Sumaira Macdonald; John D Sorkin

doi:10.1016/j.jvs.2024.07.091

Impact of the type of anesthesia on adverse events during transcarotid artery revascularization

J Vasc Surg. 2024 Aug 22:S0741-5214(24)01662-8. doi: 10.1016/j.jvs.2024.07.091. Online ahead of print.

Authors

Brajesh K Lal¹, Minerva Mayorga-Carlin², Shalini Sahoo³, Richard Cambria², Joseph D Raffetto⁴, Warren Gasper⁵, Mila Ju⁶, Sumaira Macdonald⁷, John D Sorkin⁸

Affiliations

¹ Department of Vascular Surgery, University of Maryland School of Medicine, Vascular Service, Baltimore VA Medical Center, Baltimore, MD; Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD. Electronic address: blal@som.umaryland.edu.
² Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD.
³ Department of Vascular Surgery, University of Maryland School of Medicine, Vascular Service, Baltimore VA Medical Center, Baltimore, MD.
⁴ Division of Vascular and Endovascular Surgery, St Elizabeth's Medical Center, Boston, MA; Department of Surgery, Harvard Medical School, Vascular Service, VA Boston Healthcare System, Boston, MA.
⁵ Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco, Vascular Service, San Francisco VA Medical Center, San Francisco, CA, USA; Department of Vascular and Endovascular Surgery, Lehigh Valley Health Network, Allentown, PA, USA.
⁶ Silk Road Medical, Sunnyvale, CA.
⁷ Department of Medicine, University of Maryland School of M, Baltimore VA Medical Center, Baltimore, MD, USA.
⁸ Department of Medicine, University of Maryland School of Medicine, Geriatric Research, Education, and Clinical Center, Baltimore VA Medical Center, Baltimore, MD, USA.

PMID: 39179003
DOI: 10.1016/j.jvs.2024.07.091

Abstract

Objective: The use of local or regional anesthesia (LRA) is encouraged during transcarotid artery revascularization (TCAR) because the procedure is performed through a small incision. LRA permits neurologic evaluation during the procedure and may reduce periprocedural cardiac morbidity compared with general anesthesia (GA). There is limited and conflicting information regarding the preferred anesthesia to use during TCAR. We compared periprocedural clinical and technical complications, and intraprocedural performance metrics of TCAR performed under GA vs LRA.

Methods: Patient, lesion, physician, and procedural information was collected in a worldwide quality assurance program of consecutive TCAR procedures. A composite clinical adverse event rate (death, stroke, transient ischemic attack, myocardial infarction) and a composite technical adverse event rate (aborted procedure, conversion to carotid endarterectomy, bleeding, dissection, cranial-nerve injury, device failure) in the periprocedural period were computed. Four intraprocedural performance measures (flow-reversal time, fluoroscopy time, contrast volume, and skin-to-skin time) were recorded. Deidentified data were analyzed independently at the Center for Vascular Research, University of Maryland. Poisson regressions were used to assess the impact of anesthesia type on adverse event rates. Linear regressions were used to compare performance measures.

Results: A total of 27,043 TCARs were performed by 1456 physicians between 2012 and 2021. A majority of patients (83%) received GA, and this proportion increased over time (R² = 0.74; P < .0001). Some physicians (33.4%) used LRA in some of their procedures; only 2.7% used LRA in all of their procedures. Clinical risk factors were more common in the LRA group (P < .0001) and anatomic risk factors in the GA group (P < .0001); these differences were adjusted for in subsequent analyses. LRA was more likely to be used by vascular surgeons and by physicians with higher prior transfemoral carotid stenting experience (P < .0001). When comparing GA vs LRA, clinical adverse events (1.49%; 95% confidence interval [CI], 1.3-1.8 vs 1.55%; 95% CI, 1.2-2.0; P = .78), technical adverse events (5.6%; 95% CI, 5.2-6.2 vs 5.3%; 95% CI, 4.5-6.3; P = .47), and intraprocedural performance measures did not differ by type of anesthesia.

Conclusions: Almost two-thirds of physicians performed TCAR exclusively under GA, and the overall proportion of procedures performed under GA increased over time. A larger fraction of patients with severe medical risk factors received LRA vs GA, whereas a larger fraction of patients with anatomic risk-factors received GA. Periprocedural clinical and technical adverse events did not differ by type of anesthesia. Intraprocedural performance metrics that drive procedural cost were similar between groups; potential differences in procedural cost driven by anesthetic choice require further study.

Keywords: Xxxx.