Stroke. 2009;40:e584-e585
Published online before print August 20, 2009,
doi: 10.1161/STROKEAHA.109.558288
(Stroke. 2009;40:e584.)
© 2009 American Heart Association, Inc.
Local Versus General Anesthetic for Carotid Endarterectomy
Kittipan Rerkasem, MD, PhD
Peter M. Rothwell, MD, PhD, FRCP, FMedSci
From Department of Surgery (K.R.), Chiang Mai University, Chiang Mai, Thailand; Stroke Prevention Research Unit (P.M.R.), University of Oxford, Oxford, UK.
Correspondence Dr Kittipan Rerkasem, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand 50200. E-mail krerkase{at}mail.med.cmu.ac.th
Graeme J. Hankey MD, FRCP Section Editor:
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Introduction
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Carotid endarterectomy reduces the risk of stroke in people
with recently symptomatic 70% to 99% stenosis and, to a lesser
extent, in people with 50% to 69% stenosis.
1 However, benefit
requires a low operative risk,
1 which may depend on the type
of anesthetic used. In our previous Cochrane review of several
small, randomized control trials (RCT) of carotid endarterectomy
using local anesthesia (LA) vs general anesthesia published
during 1966 to 2007, there was a trend toward lower operative
mortality with LA and no difference in risk of stroke,
2,3 but
statistical power was limited.
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Objectives
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We aimed to update the review of operative risks in RCT of carotid
endarterectomy using LA vs general anesthesia.
4
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Search Strategy
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Using the same search strategies and inclusion criteria as previous
versions of the review,
2,3 2 reviewers independently searched
MEDLINE, EMBASE, and Index to Scientific and Technical Proceedings
(all to November 2008). We also searched the Stroke Group Trial
register (September 2008), hand-searched 6 relevant journals
up to September 2008, and searched the reference list of articles
identified.
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Selection Criteria
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The selection criteria included RCT reporting the risk of stroke
or death within 30 days of carotid endarterectomy using LA vs
general anesthesia.
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Data Collection and Analysis
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Two reviewers selected studies for inclusion, assessed trial
quality, and extracted the data independently. The OR were calculated
by the Peto method. Heterogeneity between studies was assessed
by using the I
2 statistics.
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Main Results
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We identified 1 new, large RCT (GALA Trial)
5 with 3526 randomized
patients. Meta-analysis of the GALA trial with the 9 previous
smaller RCT showed no evidence of a reduction in operative strokes
or deaths (OR, 0.85; 95% CI, 0.63–1.16;
Table). There
was a nonsignificant trend toward fewer operative deaths with
LA. As expected, LA was associated with a substantial reduction
in use of arterial shunts.
View this table:
[in this window]
[in a new window]
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Table. Odds of Operative Complications During the 30 Days After Surgery in 10 RCT of Carotid Endarterectomy Performed With LA vs GA
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Implications for Practice
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Patients and surgeons can choose either anesthetic technique,
depending on the clinical situation and preferences.
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Implications for Research
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Analysis of currently available RCT is underpowered to reliably
determine the effect of LA vs general anesthesia on operative
mortality. More RCT are needed.
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Acknowledgments
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Disclosures
None.
Received May 19, 2009;
accepted May 25, 2009.
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References
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1. Rothwell PM, Eliasziw M, Gutnikov SA, Fox AJ, Taylor DW, Mayberg MR, Warlow CP, Barnett HJ. Carotid Endarterectomy Trialists’ Collaboration. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis.
Lancet. 2003; 361: 107–116.
[CrossRef][Medline]
[Order article via Infotrieve]2. Rerkasem K, Bond R, Rothwell PM. Local versus general anaesthesia for carotid endarterectomy. Cochrane. Database. Syst. Rev. 2004; CD000126.
3. Rerkasem K, Rothwell PM. Local versus general anaesthetic for carotid endarterectomy. Stroke. 2008; 36: 169–170.[CrossRef]
4. Rerkasem K, Rothwell PM. Local versus general anaesthesia for carotid endarterectomy. Cochrane. Database. Syst. Rev. 2009; CD000126.
5. GALA Trial Collaborative Group. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet. 2008; 372: 2132–2142.[CrossRef][Medline]
[Order article via Infotrieve]
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Introduction
Objectives