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. 2010 Feb 17;2010(2):CD005953.
doi: 10.1002/14651858.CD005953.pub2.

Extracranial-intracranial arterial bypass surgery for occlusive carotid artery disease

Felix Fluri  1 , Stefan Engelter, Philippe Lyrer
Affiliations

Extracranial-intracranial arterial bypass surgery for occlusive carotid artery disease

Felix Fluri et al. Cochrane Database Syst Rev. .

Abstract

Background: The EC/IC Bypass Study Group found no benefit of extracranial to intracranial (EC/IC) bypass surgery over medical therapy in patients with symptomatic carotid artery occlusion (sCAO). However, the study was criticised for many reasons and the real effect of this treatment is still not known conclusively.

Objectives: To determine whether bypass surgery plus medical care is superior to medical care alone in patients with sCAO.

Search strategy: We searched the Cochrane Stroke Group Trials Register (last searched June 2009). In addition, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2006), MEDLINE (1966 to June 2009) and EMBASE (1980 to June 2009). We also searched ongoing trials and research registers, checked reference lists of relevant articles, and contacted colleagues, trial authors and researchers.

Selection criteria: Randomised controlled trials (RCT) and non-random studies of EC/IC bypass surgery plus best medical treatment compared with best medical treatment alone to prevent subsequent stroke, improve cerebral haemodynamics and reduce dependency after stroke.

Data collection and analysis: Two review authors independently selected studies for inclusion, and extracted data items on the number of outcome events onto a data extraction form. We only analysed secondary outcomes if the study provided information on at least one primary outcome. We also used intention-to-treat analysis where possible.

Main results: We included 21 trials, including two RCTs, involving 2591 patients. For all endpoints, no benefit of EC/IC bypass surgery was shown either in the RCTs (any death: odds ratio (OR) 0.81, 95% confidence interval (CI) 0.62 to 1.05, P = 0.11; stroke: OR 0.99, 95% CI 0.79 to 1.23, P = 0.91; death and dependency: OR 0.94, 95% CI 0.74 to 1.21, P = 0.64), or in the non-RCTs (any death: OR 1.00, 95% CI 0.62 to 1.62, P = 0.99; stroke: OR 0.80, 95% CI 0.54 to 1.18, P = 0.25; death and dependency: OR 0.80, 95% CI 0.50 to 1.29, P = 0.37).

Authors' conclusions: EC/IC bypass surgery in patients with sCAO disease was neither superior nor inferior to medical care alone. However, most studies included patients irrespective of their cerebral haemodynamics. Participation in an ongoing RCT, which is restricted to patients with impaired haemodynamics, is recommended as these patients might benefit from bypass surgery.

PubMed Disclaimer

Conflict of interest statement

The authors received an in‐house grant from the Department of Neurology, University Hospital Basel, to perform the review.

Figures

1.1
1.1. Analysis
Comparison 1 EC/IC bypass versus best medical treatment: RCTs only, Outcome 1 Death from all causes.
1.2
1.2. Analysis
Comparison 1 EC/IC bypass versus best medical treatment: RCTs only, Outcome 2 Any stroke during follow up.
1.3
1.3. Analysis
Comparison 1 EC/IC bypass versus best medical treatment: RCTs only, Outcome 3 Death or dependency.
1.4
1.4. Analysis
Comparison 1 EC/IC bypass versus best medical treatment: RCTs only, Outcome 4 Vascular death.
1.5
1.5. Analysis
Comparison 1 EC/IC bypass versus best medical treatment: RCTs only, Outcome 5 Stroke, serious vascular events or vascular death.
1.6
1.6. Analysis
Comparison 1 EC/IC bypass versus best medical treatment: RCTs only, Outcome 6 Myocardial infarction.
1.7
1.7. Analysis
Comparison 1 EC/IC bypass versus best medical treatment: RCTs only, Outcome 7 Ischaemic stroke.
2.1
2.1. Analysis
Comparison 2 EC/IC bypass versus best medical treatment: all studies, Outcome 1 Death from all causes.
2.2
2.2. Analysis
Comparison 2 EC/IC bypass versus best medical treatment: all studies, Outcome 2 Any stroke during follow up.
2.3
2.3. Analysis
Comparison 2 EC/IC bypass versus best medical treatment: all studies, Outcome 3 Death or dependency.
2.4
2.4. Analysis
Comparison 2 EC/IC bypass versus best medical treatment: all studies, Outcome 4 Vascular death.
2.5
2.5. Analysis
Comparison 2 EC/IC bypass versus best medical treatment: all studies, Outcome 5 Stroke, serious vascular events or vascular death.
2.6
2.6. Analysis
Comparison 2 EC/IC bypass versus best medical treatment: all studies, Outcome 6 Myocardial infarction.
2.7
2.7. Analysis
Comparison 2 EC/IC bypass versus best medical treatment: all studies, Outcome 7 Ischaemic stroke.
2.8
2.8. Analysis
Comparison 2 EC/IC bypass versus best medical treatment: all studies, Outcome 8 Intracranial haemorrhage.
2.9
2.9. Analysis
Comparison 2 EC/IC bypass versus best medical treatment: all studies, Outcome 9 Transient ischaemic attack or amaurosis fugax.
2.10
2.10. Analysis
Comparison 2 EC/IC bypass versus best medical treatment: all studies, Outcome 10 Normalisation of cerebral haemodynamics.
3.1
3.1. Analysis
Comparison 3 Haemodynamic compromise as selection criterion for EC/IC bypass, Outcome 1 Any stroke during follow up.
3.2
3.2. Analysis
Comparison 3 Haemodynamic compromise as selection criterion for EC/IC bypass, Outcome 2 Death from all causes.
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Update of

References

References to studies included in this review

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