The benefit of local (LA) over general (GA) anaesthesia and the rationale of intraoperative
imaging strategies during carotid endarterectomy (CEA) is under debate. This study
analyses the associations between patient characteristics, LA and intraoperative imaging
strategies and the in-hospital stroke and death rates in elective CEA over a 16-years
Patients and methods
All consecutive patients treated by elective CEA between January 2004 and December
2019 (n=1.872, median 71 years, 70% male, 37% symptomatic) were included. All patients were
neurologically assessed before and within 48 hours after CEA. The primary outcome
event was the combined rate of any in-hospital stroke or death. Secondary outcome
events were the combined rates of any in-hospital major stroke (modified Rankin scale
[mRS] 3–5) or death, stroke, minor stroke (mRS 0-2), major stroke, and death alone.
To detect changes over time, we analysed four quartiles (2004–2007, 2008–2011, 2012–2015,
2016–2019) of this cohort. Statistical analysis comprised trend tests, univariate
and multivariable logistic regression.
Median patient age increased from 68 to 73 years (p<0.0001). Over time, LA (from 28% to 91%) and intraoperative imaging (angiography,
2.8% to 98.1%, DUS, 0% to 78.2%) were applied more frequently. Surgical techniques
did not change. The in-hospital stroke/death and major stroke/death rates decreased
from 3.7% to 1.5% (p=0.04) and 2.8 to 0.9% (p=0.01), respectively, corresponding to a relative risk decline of 7% and 12% per year.
Multivariable analysis revealed that LA (OR 0.25, 95%CI 0.1–0.62) and intraoperative
angiography (OR 0.09, 95%CI: 0.10–0.81) were associated with lower in-hospital major
stroke and death rates.
These data demonstrate a decline in the combined rates of any in-hospital major stroke
or death after non-emergent CEA over time. Locoregional anaesthesia and intraoperative
quality control were associated with these improvements and might be worthwhile in