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Local versus general anaesthesia for carotid endarterectomyRerkasem K, Rothwell PM
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SummaryLocal versus general anaesthesia for carotid endarterectomyWe still need more evidence to determine the best type of anaesthesia for carotid endarterectomy. About 20% of strokes result from narrowing of the carotid artery (the main artery supplying blood to the brain). This diseased artery contained an unstable atheromatous plaque, which gives rise to the embolus. Carotid endarterectomy is an operation to remove this narrowing together with unstable plaque and therefore decrease the risk of stroke. Nevertheless there is a 5% to 7% risk of the operation itself causing a stroke, and this may be influenced by the type of anaesthetic. This review includes nine randomised trials of 812 operations, and 47 non-randomised studies of 24,181 operations. However, from the currently available data we cannot determine whether carotid endarterectomy is best performed under local anaesthesia or general anaesthesia. Non-randomised studies suggest that local anaesthesia is safer, but there are insufficient data from randomised studies to allow reliable conclusions to be drawn. More randomised trials are needed. The ongoing GALA Trial will provide much more reliable evidence than is currently available.
This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2009 Issue 2, Copyright © 2009 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).
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October 21. 1996 AbstractBackgroundCarotid endarterectomy reduces the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks which may be lessened by performing the operation under local rather than general anaesthetic. This is an update of a Cochrane review first published in 1996, and previously updated in 2004. ObjectivesTo assess the risks of endarterectomy under local compared with general anaesthetic. Search strategyWe searched the Cochrane Stroke Group Trials Register (last searched December 2007), MEDLINE (1966 to April 2007) EMBASE (1980 to April 2007) and Index to Scientific and Technical Proceedings (ISTP, 1980 to April 2007). We also handsearched six relevant journals to April 2007, and searched the reference lists of articles identified. For the previous version of this review we handsearched a further seven journals to 2002 and in August 2001 advertised the review in Vascular News, a newspaper for European vascular specialists. Selection criteriaRandomised trials and non-randomised studies comparing carotid endarterectomy under local versus general anaesthetic. Data collection and analysisTwo review authors assessed trial quality and extracted the data independently. Main resultsNine randomised trials involving 812 operations, and 47 non-randomised studies involving 24,181 operations were included. Meta-analysis of the randomised studies showed that there was no evidence of a reduction in the odds of operative stroke, but the use of local anaesthetic was associated with a significant reduction in local haemorrhage (odds ratio 0.30, 95% confidence interval 0.12 to 0.77) within 30 days of the operation. However, the randomised trials were too small to allow reliable conclusions to be drawn, and in some studies intention-to-treat analyses were not possible because of exclusions. Meta-analsis of the non-randomised studies showed that the use of local anaesthetic was associated with significant reductions in the odds of stroke (38 studies), death (42 studies), stroke or death (27 studies), myocardial infarction (27 studies), and pulmonary complications (seven studies), within 30 days of the operation. The methodological quality of the non-randomised trials was questionable. Thirteen of the non-randomised studies were prospective and 36 reported on a consecutive series of patients. In eleven non-randomised studies the number of arteries, as opposed to the number of patients, was unclear. Authors' conclusionsThere is insufficient evidence from randomised trials comparing carotid endarterectomy performed under local and general anaesthetic. Non-randomised studies suggest potential benefits with the use of local anaesthetic, but these studies may be biased. |