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Meta-Analysis
. 2021 Oct 13;10(10):CD000126.
doi: 10.1002/14651858.CD000126.pub5.

Local versus general anaesthesia for carotid endarterectomy

Amaraporn Rerkasem  1 , Saritphat Orrapin  2 , Dominic Pj Howard  3 , Sothida Nantakool  1 , Kittipan Rerkasem  1   4
Affiliations
Meta-Analysis

Local versus general anaesthesia for carotid endarterectomy

Amaraporn Rerkasem et al. Cochrane Database Syst Rev. .

Abstract

Background: Carotid endarterectomy may significantly reduce the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks that may be minimised by performing the operation under local rather than general anaesthetics. This is an update of a Cochrane Review first published in 1996, and previously updated in 2004, 2008, and 2013.

Objectives: To determine whether carotid endarterectomy under local anaesthetic: 1) reduces the risk of perioperative stroke and death compared with general anaesthetic; 2) reduces the complication rate (other than stroke) following carotid endarterectomy; and 3) is acceptable to individuals and surgeons.

Search methods: We searched CENTRAL, MEDLINE, Embase, and two trials registers (to February 2021). We also reviewed reference lists of articles identified.

Selection criteria: Randomised controlled trials (RCTs) comparing the use of local anaesthetics to general anaesthetics for people having carotid endarterectomy were eligible.

Data collection and analysis: Three review authors independently extracted data, assessed risk of bias, and evaluated quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) tool. We calculated a pooled Peto odds ratio (OR) and corresponding 95% confidence interval (CI) for the following outcomes that occurred within 30 days of surgery: stroke, death, ipsilateral stroke, stroke or death, myocardial infarction, local haemorrhage, and arteries shunted.

Main results: We included 16 RCTs involving 4839 participants, of which 3526 were obtained from the single largest trial (GALA). The main findings from our meta-analysis showed that, within 30 days of operation, neither incidence of stroke nor death were significantly different between local and general anaesthesia. Of these, the incidence of stroke in the local and general anaesthesia groups was 3.2% and 3.5%, respectively (Peto odds ratio (OR) 0.91, 95% confidence interval (CI) 0.66 to 1.26; P = 0.58; 13 studies, 4663 participants; low-quality evidence). The rate of ipsilateral stroke under both types of anaesthesia was 3.1% (Peto OR 1.03, 95% CI 0.71 to 1.48; P = 0.89; 2 studies, 3733 participants; low-quality evidence). The incidence of stroke or death in the local anaesthesia group was 3.5%, while stroke or death incidence was 4.1% in the general anaesthesia group (Peto OR 0.85, 95% CI 0.62 to 1.16; P = 0.31; 11 studies, 4391 participants; low-quality evidence). A lower rate of death was observed in the local anaesthetic group but evidence was of low quality (Peto OR 0.61, 95% CI 0.35 to 1.06; P = 0.08; 12 studies, 4421 participants).

Authors' conclusions: The incidence of stroke and death were not convincingly different between local and general anaesthesia for people undergoing carotid endarterectomy. The current evidence supports the choice of either approach. Further high-quality studies are still needed as the evidence is of limited reliability.

PubMed Disclaimer

Conflict of interest statement

AR: none known. SO: none known. DPJH: none known. SN: none known. KR: none known.

Figures

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1
PRISMA study flow diagram
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Risk of bias summary: review authors' judgements about each risk of bias item for each included study
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3
Funnel plot of comparison 1: local versus general anaesthetic, randomised trials. Outcome 1.1: any stroke within 30 days of operation
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Funnel plot of comparison 1: local versus general anaesthetic, randomised trials. Outcome 1.2: death within 30 days of operation
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5
Funnel plot of comparison 1: local versus general anaesthetic, randomised trials. Outcome 1.4: stroke or death within 30 days of operation
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Funnel plot of comparison 1: local versus general anaesthetic, randomised trials. Outcome 1.5: myocardial infarction within 30 days of operation
1.1
1.1. Analysis
Comparison 1: Local versus general anaesthetic: randomised trials, Outcome 1: Any stroke within 30 days of operation
1.2
1.2. Analysis
Comparison 1: Local versus general anaesthetic: randomised trials, Outcome 2: Death within 30 days of operation
1.3
1.3. Analysis
Comparison 1: Local versus general anaesthetic: randomised trials, Outcome 3: Ipsilateral stroke within 30 days of operation
1.4
1.4. Analysis
Comparison 1: Local versus general anaesthetic: randomised trials, Outcome 4: Stroke or death within 30 days of operation
1.5
1.5. Analysis
Comparison 1: Local versus general anaesthetic: randomised trials, Outcome 5: Myocardial infarction within 30 days of operation
1.6
1.6. Analysis
Comparison 1: Local versus general anaesthetic: randomised trials, Outcome 6: Local haemorrhage
1.7
1.7. Analysis
Comparison 1: Local versus general anaesthetic: randomised trials, Outcome 7: Sensitivity analysis: random‐effects model, local haemorrhage
1.8
1.8. Analysis
Comparison 1: Local versus general anaesthetic: randomised trials, Outcome 8: Arteries shunted
1.9
1.9. Analysis
Comparison 1: Local versus general anaesthetic: randomised trials, Outcome 9: Sensitivity analysis: random‐effects model, arteries shunted
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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References to other published versions of this review

Rerkasem 2004
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