Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting)

Question

We wanted to compare the effect of routine shunting versus selective or no shunting during carotid endarterectomy, and to assess the effect of different methods for selection of people for shunting.

Background

About 20% of strokes result from narrowing of the carotid artery (the main artery supplying blood to the brain). Carotid endarterectomy is an operation to remove this narrowing and therefore reduce the risk of stroke. However, there is a 5% to 10% risk of the operation itself causing a stroke. The use of a silicon tube, or shunt, as a temporary bypass can reduce the length of time that blood flow to the brain is interrupted during the operation. This may reduce the risk of perioperative stroke but could also result in arterial wall damage and therefore increase the risk of stroke. Shunt surgery falls into three categories. Firstly, in routine shunting, the surgeon inserts a shunt in every patient. Secondly, in selective shunting, the surgeon only uses a shunt in patients with an inadequate blood supply to the brain following clamping; various cerebral monitoring techniques, such as ultrasound for predicting who needs a shunt, have been used in this policy. Thirdly, in no shunting, surgeons do not employ shunts at all.

Study characteristics

We identified six studies up to August 2013, for inclusion in the review. These studies included a total of 1270 participants. Three of the trials compared routine shunting with no shunting, one trial compared routine shunting versus selective shunting, and another two trials compared different methods of monitoring in selective shunting. We have not yet identified any trials that compared selective shunting with no shunting. All the included trials assessed the use of shunting in people undergoing endarterectomy under general anaesthetic. The age of the participants ranged from 40 to 89 years, and overall, there were more male than female participants. Where reported, participants were followed up for no longer than 30 days.

Key results

There is still no evidence for the use of a carotid shunt during carotid endarterectomy. This review suggests a benefit from the use of a shunt, but the overall results were not statistically significant. More trials are needed.

Quality of the evidence

There were significant problems with the quality of the randomised trials and, overall, the reporting of study methodology was poor.

Authors' conclusions: 

This review concluded that the data available were too limited to either support or refute the use of routine or selective shunting in carotid endarterectomy. Large scale randomised trials of routine shunting versus selective shunting are required. No method of monitoring in selective shunting has been shown to produce better outcomes.

Read the full abstract...
Background: 

Temporary interruption of cerebral blood flow during carotid endarterectomy can be avoided by using a shunt across the clamped section of the carotid artery. This may improve outcome. This is an update of a Cochrane review originally published in 1996 and previously updated in 2009.

Objectives: 

To assess the effect of routine versus selective or no shunting during carotid endarterectomy, and to assess the best method for selecting people for shunting.

Search strategy: 

We searched the Cochrane Stroke Group Trials Register (last searched August 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2013, Issue 8), MEDLINE (1966 to August 2013), EMBASE (1980 to August 2013) and Index to Scientific and Technical Proceedings (1980 to August 2013). We handsearched journals and conference proceedings, checked reference lists, and contacted experts in the field.

Selection criteria: 

Randomised and quasi-randomised trials of routine shunting compared with no shunting or selective shunting, and trials that compared different shunting policies in people undergoing carotid endarterectomy.

Data collection and analysis: 

Three review authors independently performed the searches and applied the inclusion criteria. For this update, we identified two new relevant randomised controlled trials.

Main results: 

We included six trials involving 1270 participants in the review: three trials involving 686 participants compared routine shunting with no shunting, one trial involving 200 participants compared routine shunting with selective shunting, one trial involving 253 participants compared selective shunting with and without near-infrared refractory spectroscopy monitoring, and the other trial involving 131 participants compared shunting with a combination of electroencephalographic and carotid pressure measurement with shunting by carotid pressure measurement alone. In general, reporting of methodology in the included studies was poor. For most studies, the blinding of outcome assessors and the report of prespecified outcomes were unclear. For routine versus no shunting, there was no significant difference in the rate of all stroke, ipsilateral stroke or death up to 30 days after surgery, although data were limited. No significant difference was found between the groups in terms of postoperative neurological deficit between selective shunting with and without near-infrared refractory spectroscopy monitoring, However, this analysis was inadequately powered to reliably detect the effect. There was no significant difference between the risk of ipsilateral stroke in participants selected for shunting with the combination of electroencephalographic and carotid pressure assessment compared with pressure assessment alone, although again the data were limited.

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