Local versus general anaesthesia for carotid endarterectomy.

BACKGROUND: Carotid endarterectomy reduces the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks which may be lessened by performing the operation under local rather than general anaesthetic. OBJECTIVES: The objective of this review was to assess the effect of endarterectomy under local compared with general anaesthetic. SEARCH STRATEGY: We searched the Cochrane Stroke Group trials register, Medline (1966 to 1995), Embase (1980 to 1995), and Index to Scientific and Technical Proceedings (1980 to 1994). We handsearched Annals of Surgery (1981 to 1995), British Journal of Surgery (1985 to 1995), European Journal of Vascular Surgery (1988 to 1995) and World Journal of Surgery (1978 to 1995). Reference lists of articles were searched. SELECTION CRITERIA: Randomised trials and non-randomised studies comparing carotid endarterectomy under local versus general anaesthetic. DATA COLLECTION AND ANALYSIS: One reviewer selected studies for inclusion and another independently checked the decisions. Two reviewers assessed trial quality and independently extracted the data. MAIN RESULTS: Three randomised trials involving 143 patients, and 17 non-randomised studies involving about 5970 patients were included. The methodological quality of the randomised trials was questionable. Two of the non-randomised studies were prospective and 12 reported on a consecutive series of patients. In nine non-randomised studies the number of patients, as opposed to the number of arteries, was unclear. There were insufficient data to enable conclusions to be drawn from the randomised trials. In 15 non-randomised studies, no significant difference was shown between local and general anaesthetic in deaths within 30 days of operation (odds ratio 0.61, 95% confidence interval 0.32 to 1.16). Non-randomised studies showed that local anaesthetic was associated with a significant reduction in the odds of stroke (15 studies), stroke or death (14 studies), myocardial infarction (12 studies), and pulmonary complications (five studies), within 30 days of the operation. Patient and surgeon satisfaction were not reported in any study. REVIEWER'S CONCLUSIONS: There is not enough evidence from randomised trials comparing carotid endarterectomy performed under local as opposed to general anaesthetic. Non-randomised studies suggest potential benefits with local anaesthetic. However these studies are likely to be significantly biased.

Local versus general anaesthesia in carotid endarterectomy: a systematic review of the evidence.

OBJECTIVE: To determine whether carotid endarterectomy under local anaesthesia is safer and as effective as under general anaesthesia. DESIGN: Systematic review of the randomised and non-randomised studies. MATERIALS: Studies were identified from the Cochrane Stroke Group's database plus additional handsearching and electronic searching. METHODS: Two authors independently selected studies for inclusion and extracted details of trial quality and data on death, any stroke, myocardial infarction and other operative complications. Meta-analysis was performed using the Peto method. RESULTS: There were 17 non-randomised studies (about 5970 patients) and only three randomised studies (143 patients). The non-randomised studies suggested that the use of local anaesthesia may be associated with clinically important reductions (approximately 50%) in the odds of stroke, stroke or death, myocardial infarction and pulmonary complications during the perioperative period, and with reductions in hospital stay. There were far too little data from the randomised trials to confirm or refute these findings: only one death and seven strokes were reported. CONCLUSIONS: Non-randomised studies suggest potentially important benefits from performing carotid endarterectomy under local anaesthesia. However, these studies were seriously flawed and can only be hypothesis generating. The results must be confirmed in large well-designed randomised trials before any recommendations on the use of local anaesthetic can be made.