General versus nongeneral anesthesia in transfemoral and transradial carotid artery stenting

The optimal anesthetic strategy for carotid artery stenting (CAS) remains uncertain. General anesthesia (GA) ensures immobility and airway control but may increase hemodynamic instability, whereas monitored anesthesia care or local anesthesia permits real-time neurological assessment. This multicenter study evaluated the association between anesthetic modality and clinical outcomes after CAS.

Data were prospectively collected from 15 comprehensive stroke centers in the United States between January 2023 and December 2024. Adults undergoing CAS for atherosclerotic carotid stenosis were included. Propensity score matching (1:2 nearest neighbor, without replacement) was performed using preprocedural National Institutes of Health stroke scale to balance baseline differences between GA and non-GA cohorts. The primary outcomes were 30-day procedure-related mortality, ischemic or hemorrhagic stroke, and myocardial infarction. Logistic regression identified independent predictors of mortality.

Among 888 patients (222 GA, 666 non-GA), the groups were well-balanced after matching (220 vs 668). Overall complication rates were low (6%-7%). Thirty-day mortality was 4.1% with GA vs 1.8% with non-GA (P = .14). In regression, non-GA was associated with lower all-cause mortality (odds ratio, 0.11; 95% confidence interval, 0.01-0.85; P = .03). Functional recovery was superior with non-GA (mean 30-day modified Rankin Scale 1.25 vs 1.60; P = .012). Length of stay was shorter in the non-GA group (5.2 days vs 6.2 days; P = .021).

Both anesthetic approaches were safe, but non-GA was associated with slightly better functional outcomes and lower mortality rates. When clinically feasible, monitored anesthesia care or local anesthesia may offer superior periprocedural safety and recovery in CAS.