Local versus general anaesthesia for carotid endarterectomy
Abstract
Background
Carotid 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.
Objectives
The aim of this review was to assess the risks of endarterectomy under local compared with general anaesthetic.
Search methods
We searched the Stroke Group trials register (April 2003), MEDLINE (1966 to April 2003), EMBASE (1980 to 2002), and Index to Scientific and Technical Proceedings (1980 to 1994). We handsearched 13 relevant journals up to 2002, and searched the reference lists of articles identified. We also advertised the review in Vascular News (a newspaper for European vascular specialists) in August 2001.
Selection criteria
Randomised trials and non‐randomised studies comparing carotid endarterectomy under local versus general anaesthetic.
Data collection and analysis
One reviewer selected studies for inclusion and another independently checked the decisions. Two reviewers assessed trial quality and independently extracted the data.
Main results
Seven randomised trials involving 554 operations, and 41 non‐randomised studies involving 25622 operations were included. The methodological quality of the non‐randomised trials was questionable. Eleven of the non‐randomised studies were prospective and 29 reported on a consecutive series of patients. In nine non‐randomised studies the number of arteries, as opposed to the number of patients, was unclear. Meta‐analysis of the non‐randomised studies showed that the use of local anaesthetic was associated with significant reductions in the odds of death (35 studies), stroke (31 studies), stroke or death (26 studies), myocardial infarction (22 studies), and pulmonary complications (7 studies), within 30 days of the operation. Meta‐analysis of the randomised studies showed that the use of local anaesthetic was associated with a significant reduction in local haemorrhage (OR = 0.31, 95% CI = 0.12 to 0.79) within 30 days of the operation, but there was no evidence of a reduction in the odds of operative stroke. However, the 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.
Authors' conclusions
There 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. More randomised studies are needed.
PICOs
Plain language summary
We 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). Carotid endarterectomy is an operation to remove this narrowing 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. However, from the currently available data we cannot determine whether carotid endarterectomy is best performed under local anaesthesia (LA) or general anaesthesia (GA). Non‐randomised studies suggest that LA 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.
