Local Versus General Anesthetic for Carotid Endarterectomy
Graeme J. Hankey MD, FRCP Section Editor:
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.
We aimed to update the review of operative risks in RCT of carotid endarterectomy using LA vs general anesthesia.4
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.
The selection criteria included RCT reporting the risk of stroke or death within 30 days of carotid endarterectomy using LA vs general anesthesia.
Data Collection and Analysis
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 I2 statistics.
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.
Implications for Practice
Patients and surgeons can choose either anesthetic technique, depending on the clinical situation and preferences.
Implications for Research
Analysis of currently available RCT is underpowered to reliably determine the effect of LA vs general anesthesia on operative mortality. More RCT are needed.
- Received May 19, 2009.
- Accepted May 25, 2009.
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.
Rerkasem K, Bond R, Rothwell PM. Local versus general anaesthesia for carotid endarterectomy. Cochrane. Database. Syst. Rev. 2004; CD000126.
Rerkasem K, Rothwell PM. Local versus general anaesthesia for carotid endarterectomy. Cochrane. Database. Syst. Rev. 2009; CD000126.