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Increased Risk Of General Anesthesia Among Diabetic Patients Undergoing Carotid Endarterectomy

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Caron Rockman, MD, Stephanie S. Saltzberg, MD, Thomas Maldonado, MD, Glenn R. Jacobowitz, MD, Mark A. Adelman, MD, Paul J. Gagne, MD, Neal S. Cayne, MD, Matthew M. Nalbandian, MD, Patrick J. Lamparello, MD, Thomas S. Riles, MD.
New York University, New York, NY, USA.

Objectives: Patients with diabetes mellitus have been shown to have an increased incidence of complications following elective major vascular surgery. The objective of this study was to evaluate a large series of diabetic patients undergoing carotid endarterectomy (CEA), to determine if outcome differed from non-diabetic patients, and to examine predisposing factors of poor outcome among diabetic patients.
Methods: A retrospective review of a prospectively compiled database was performed. From 1992 through 2000, 2151 CEA’s were performed at our institution. Of these, 507 were in diabetic patients (23.6%), while the remaining 1644 procedures were in non-diabetic patients (76.4%).
Results: Diabetic patients were significantly more likely than non-diabetic patients to have hypertension (70.8% vs. 64.5%, p=.01) and cardiac disease (54.6% vs. 49.1%, p=.03). They were more likely than non-diabetic patients to be symptomatic prior to surgery (52.5% vs. 47.1%, p=.04), and to have sustained a preoperative stroke (21.3% vs. 17.7%, p=.07). There were no differences noted in other recorded demographic factors, or in intraoperative factors between diabetics and non-diabetics. Despite these differences, diabetic patients had similar perioperative outcomes to non-diabetic patients, including perioperative myocardial infarction (0.6% vs. 0.4%, p=ns), perioperative death (0.8% vs. 0.5%, p=ns), and perioperative neurologic events including transient ischemic attack and stroke (3.2% vs. 2.4%, p=ns). However, when diabetic patients were examined in more detail, it was noted that diabetics had a significantly increased risk of perioperative stroke, myocardial infarction, or death when undergoing surgery under general rather than regional anesthesia (8.6% vs. 3.0%, p=.02). Multivariate analysis by binary logistic regression confirmed that general anesthesia was the only independent predictor of a major perioperative complication (p=.04, 95% CI 1.03-6.5) among diabetics undergoing CEA.
Conclusions: Despite an increased prevalence of cardiac disease and preoperative neurologic symptoms among diabetic patients undergoing CEA, the rates of perioperative cardiac morbidity, mortality, and stroke were equal to non-diabetic patients. Although diabetics may have an increase in complications following other major vascular surgical procedures, the presence of diabetes does not appear to increase risk following carotid endarterectomy. However, the use of a general anesthetic for CEA in diabetic patients conferred a significantly increased risk of perioperative stroke, death, or myocardial infarction. Consideration should be given towards the use of cervical block anesthesia in diabetic patients undergoing CEA.