TCAR vs CEA: Research shows fewer myocardial infarctions after TCAR with use of general anesthesia

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Transcarotid revascularization (TCAR)

A Vascular Quality Initiative (VQI) analysis uncovered a reduction in the risk of myocardial infarction after transcarotid artery revascularization (TCAR) compared to carotid endarterectomy (CEA) when general anesthesia is used—an observation mainly found in patients with symptomatic carotid artery stenosis.

The findings, recently published in the Journal of Vascular Surgery, suggest that general anesthesia use would most likely benefit patients with symptomatic carotid artery stenosis due to the decreased risk of myocardial infarction if they are treated with TCAR instead of CEA, the study authors concluded.

The investigators behind the research include first-named author Rebecca A. Marmor, MD, and Mahmoud Malas, MD, who are, respectively, fellow and chief in the division of vascular and endovascular surgery at the University of California San Diego in La Jolla. Marmor, Malas—the site principal investigator (PI) for the ROADSTER 1 and ROADSTER 2 multicenter trials of TCAR—and colleagues set out to understand the impact of anesthetic choice on perioperative outcomes among patients treated with TCAR and CEA. Though most carotid revascularization procedures are performed under general anesthesia, “prior authors have hypothesized that increasing numbers of TCAR procedures will be performed under local/regional anesthesia as surgeons’ comfort-level with the procedure increases,” they stated.

The researchers obtained all consecutive patients undergoing TCAR with the ENROUTE Transcarotid Neuroprotection System and CEA between 2016 and 2019 from the VQI TCAR Surveillance Project trial. A total of 8,132 TCAR and 57,205 CEA cases were identified, including both symptomatic and asymptomatic patients. Some 93% of CEA procedures were performed under general anesthesia, compared to 81% of TCARs. No significant association was observed in the risk of stroke or death after TCAR and CEA and the choice of anesthesia, the authors found.

However, compared with CEA under general anesthesia, equivalent patients undergoing TCAR had a 50% decreased risk of myocardial infarction (0.5% vs. 1.0%; relative risk [RR], 0.50; 95% confidence interval [CI] 0.32–0.80; p<0.01), “which was driven by risk reduction” among symptomatic patients only (0.4% vs. 1.2%; RR, 0.33;  95% CI, 0.15–0.75; p=0.01), they discovered.

The study also demonstrated there was no difference in risk of myocardial infarction among asymptomatic patients treated under general anesthesia (0.6% vs. 0.9%; RR, 0.64; 95% CI, 0.37–1.14; p=0.13). “On the other hand, when performed under local anesthesia, TCAR and CEA had similar risk of myocardial infarction independent of symptomatic status (0.3% vs. 0.4%; RR, 0.82; 95% CI, 0.18–3.7; p=0.80),” the researchers outlined in their findings.

They further noted considerable interest in performing more TCARs under local/regional anesthesia but that their data indicates most surgeons currently are performing TCAR under general anesthesia.

“When carotid revascularization is performed under general anesthesia on an asymptomatic patient, TCAR and CEA appear to have equivalent risk of postoperative myocardial infarction,” they state. “However, when revascularization is performed under general anesthesia on a symptomatic patient, TCAR offers a decreased risk of postoperative myocardial infarction as compared with CEA, despite the fact that more patients in the TCAR group had coronary artery disease. This could be partially explained by the fact that symptomatic patients have more advanced disease with unstable plaques.”

The researchers concluded: “When performed under local/regional anesthesia, regardless of symptomatic status, TCAR and CEA appear to confer the same risk of postoperative stroke, myocardial infarction and death. However, when performed under general anesthesia, symptomatic patients appear to have increased risk of myocardial infarction when treated with CEA as compared with TCAR. This difference does not persist among asymptomatic patients who appear to have equivalent risk of postoperative myocardial infarction whether treated by CEA or TCAR. We suggest that symptomatic patients with high coronary artery disease risk undergo TCAR under general anesthesia or either procedure under local/regional anesthesia to minimize risk of postoperative myocardial infarction.”

SOURCE: doi.org/10.1016/j.jvs.2021.03.037

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