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Meta-Analysis
. 2022 Jun 22;6(6):CD000190.
doi: 10.1002/14651858.CD000190.pub4.

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

Busaba Chuatrakoon  1 , Sothida Nantakool  2 , Amaraporn Rerkasem  2 , Saritphat Orrapin  3 , Dominic Pj Howard  4 , Kittipan Rerkasem  2   5   6
Affiliations
Meta-Analysis

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

Busaba Chuatrakoon et al. Cochrane Database Syst Rev. .

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. The shunt may improve the outcome. This is an update of a Cochrane review originally published in 1996 and previously updated in 2002, 2009, and 2014.

Objectives: To assess the effect of routine versus selective or no shunting, and to assess the best method for selective shunting on death, stroke, and other complications in people undergoing carotid endarterectomy under general anaesthesia.

Search methods: We searched the Cochrane Stroke Group Trials Register (last searched April 2021), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2021, Issue 4), MEDLINE (1966 to April 2021), Embase (1980 to April 2021), and the Science Citation Index Expanded (SCI-EXPANDED) (1980 to April 2021). We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform, and handsearched relevant journals, conference proceedings, and reference lists.

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 independent review authors performed data extraction, selection, and analysis. A pooled Peto odds ratio (OR) and 95% confidence interval (CI) were computed for all outcomes of interest. Best and worse case scenarios were also calculated in case of unavailable data. Two authors independently assessed risk of bias, and quality of evidence using GRADE.

Main results: No new trials were found for this updated review. Thus, six trials involving 1270 participants are included in this latest 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. Only three trials comparing routine shunting and no shunting were eligible for meta-analysis. Major findings of this comparison found that the routine shunting had less risk of stroke-related death within 30 days of surgery (best case) than no shunting (Peto odds ratio (OR) 0.13, 95% confidence interval (CI) 0.02 to 0.96, I2 not applicable, P = 0.05, low-quality evidence), the routine shunting group had a lower stroke rate within 24 hours of surgery (Peto odds ratio (OR) 0.15, 95% CI 0.03 to 0.78, I2 = not applicable, P = 0.02, low-quality evidence), and ipsilateral stroke within 30 days of surgery (best case) (Peto OR 0.41, 95% CI 0.18 to 0.97, I2 = 52%, P = 0.04, low-quality evidence) than the no shunting group. No 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 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.

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 when performed under general anaesthesia. 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.

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Conflict of interest statement

Busaba Chuatrakoon has no conflict of interest.

Sothida Nantakool has no conflict of interest.

Amaraporn Rerkasem has no conflict of interest.

Saritphat Orrapin has no conflict of interest.

Dominic PJ Howard has no conflict of interest.

Kittipan Rerkasem has no conflict of interest.

Figures

1
1
Flow diagram for updated systematic reviews
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study
1.1
1.1. Analysis
Comparison 1: Routine shunting versus no shunting, Outcome 1: Death from all causes within 30 days of surgery
1.2
1.2. Analysis
Comparison 1: Routine shunting versus no shunting, Outcome 2: Stroke‐related death within 30 days of surgery (best‐case)
1.3
1.3. Analysis
Comparison 1: Routine shunting versus no shunting, Outcome 3: Stroke‐related death within 30 days of surgery (worst‐case)
1.4
1.4. Analysis
Comparison 1: Routine shunting versus no shunting, Outcome 4: Any stroke during surgery (best‐case)
1.5
1.5. Analysis
Comparison 1: Routine shunting versus no shunting, Outcome 5: Any stroke during surgery (worst‐case)
1.6
1.6. Analysis
Comparison 1: Routine shunting versus no shunting, Outcome 6: Any stroke within 24 hours of surgery
1.7
1.7. Analysis
Comparison 1: Routine shunting versus no shunting, Outcome 7: Any stroke within 30 days of surgery
1.8
1.8. Analysis
Comparison 1: Routine shunting versus no shunting, Outcome 8: Ipsilateral stroke during surgery (best‐case)
1.9
1.9. Analysis
Comparison 1: Routine shunting versus no shunting, Outcome 9: Ipsilateral stroke during surgery (worst‐case)
1.10
1.10. Analysis
Comparison 1: Routine shunting versus no shunting, Outcome 10: Ipsilateral stroke within 30 days of surgery (best‐case)
1.11
1.11. Analysis
Comparison 1: Routine shunting versus no shunting, Outcome 11: Ipsilateral stroke within 30 days of surgery (worst‐case)
1.12
1.12. Analysis
Comparison 1: Routine shunting versus no shunting, Outcome 12: Stroke or death within 30 days of surgery (best‐case)
1.13
1.13. Analysis
Comparison 1: Routine shunting versus no shunting, Outcome 13: Stroke or death within 30 days of surgery (worst‐case)
1.14
1.14. Analysis
Comparison 1: Routine shunting versus no shunting, Outcome 14: Haemorrhage from operation site
1.15
1.15. Analysis
Comparison 1: Routine shunting versus no shunting, Outcome 15: Infection of operation site
1.16
1.16. Analysis
Comparison 1: Routine shunting versus no shunting, Outcome 16: Nerve palsy postoperatively
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References

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