Anesthetic strategies for carotid endarterectomy: impact on intraoperative stability, patient experience, and psychological outcomes

BACKGROUND: While carotid endarterectomy (CEA) is an established procedure for stroke prevention, the optimal anesthetic strategy remains debated. Regional anesthesia (RA) allows neurologic monitoring but may increase patient discomfort. A combined approach (CA) using RA with conscious sedation may offer a balance between patient safety, comfort, and psychological well-being.METHODS: We conducted a prospective bi-center observational study comparing RA and CA in 86 patients undergoing elective CEA. Perioperative parameters, patient-reported outcomes (including intraoperative stress and anxiety), and postoperative psychological distress, assessed at 30 days via the PTSD Checklist for DSM-5 (PCLS-5), were analyzed. Hemodynamic stability, complications, and satisfaction with the anesthetic technique were also evaluated.RESULTS: A total of 86 patients were included in the analysis with a mean age of 75.3±7.5 years: 38 in the RA group and 48 in the CA group. Patients in the RA group experienced significantly higher intraoperative stress (5.8 ± 3.1 vs. 2.1, P<0.0001), anxiety (1.2 vs. 0.3 ± 0.6, P<0.0001), and PCLS-5 scores (4.9 ± 5.7 vs. 1.6 ± 2.9, P=0.0008) compared to the CA group. Hemodynamic instability was more frequent in the RA group (39.5% vs. 2.1%, P<0.0001). No significant differences were observed in perioperative stroke, TIA, or cranial nerve injury. Patient satisfaction and willingness to repeat the same anesthetic technique were higher in the CA group (100% vs. 78.9%, P=0.0001).CONCLUSIONS: Compared to RA alone, combined anesthesia with conscious sedation was associated with improved intraoperative comfort, enhanced psychological outcomes, and superior hemodynamic control in patients undergoing CEA. These findings support the integration of patient-centered metrics into anesthetic planning and suggest that CA may be a preferred approach in selected patients.