Local Versus General Anesthetic for Carotid Endarterectomy
2009; Lippincott Williams & Wilkins; Volume: 40; Issue: 10 Linguagem: Inglês
10.1161/strokeaha.109.558288
ISSN1524-4628
AutoresKittipan Rerkasem, Peter M. Rothwell,
Tópico(s)Cardiac, Anesthesia and Surgical Outcomes
ResumoHomeStrokeVol. 40, No. 10Local Versus General Anesthetic for Carotid Endarterectomy Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBLocal Versus General Anesthetic for Carotid Endarterectomy Kittipan Rerkasem, MD, PhD and Peter M. Rothwell, MD, PhD, FRCP, FMedSci Kittipan RerkasemKittipan Rerkasem From Department of Surgery (K.R.), Chiang Mai University, Chiang Mai, Thailand; Stroke Prevention Research Unit (P.M.R.), University of Oxford, Oxford, UK. and Peter M. RothwellPeter M. Rothwell From Department of Surgery (K.R.), Chiang Mai University, Chiang Mai, Thailand; Stroke Prevention Research Unit (P.M.R.), University of Oxford, Oxford, UK. Originally published20 Aug 2009https://doi.org/10.1161/STROKEAHA.109.558288Stroke. 2009;40:e584–e585Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: August 20, 2009: Previous Version 1 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.ObjectivesWe aimed to update the review of operative risks in RCT of carotid endarterectomy using LA vs general anesthesia.4Search StrategyUsing 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.Selection CriteriaThe 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 AnalysisTwo 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.Main ResultsWe 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. Table. Odds of Operative Complications During the 30 Days After Surgery in 10 RCT of Carotid Endarterectomy Performed With LA vs GAOutcomeLA Event/CasesGA Event/CasesOR95% CII2 (%)GA indicates general anesthesia; I2, heterogeneity.Stroke72/211177/20810.920.67–1.280Death20/205732/20260.620.36–1.070Stroke or death78/205790/20260.850.63–1.160MI14/21119/20811.530.67–3.470Local hematoma154/2002160/19740.950.75–1.1947Cranial nerve injury217/1946186/19191.170.95–1.440Use of arterial shunt304/1959798/19410.270.23–0.3191Implications for PracticePatients and surgeons can choose either anesthetic technique, depending on the clinical situation and preferences.Implications for ResearchAnalysis of currently available RCT is underpowered to reliably determine the effect of LA vs general anesthesia on operative mortality. More RCT are needed.DisclosuresNone.FootnotesCorrespondence Dr Kittipan Rerkasem, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand 50200. E-mail [email protected] References 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.CrossrefMedlineGoogle Scholar2 Rerkasem K, Bond R, Rothwell PM. Local versus general anaesthesia for carotid endarterectomy. Cochrane. Database. Syst. Rev. 2004; CD000126.MedlineGoogle Scholar3 Rerkasem K, Rothwell PM. Local versus general anaesthetic for carotid endarterectomy. Stroke. 2008; 36: 169–170.Google Scholar4 Rerkasem K, Rothwell PM. Local versus general anaesthesia for carotid endarterectomy. Cochrane. Database. Syst. Rev. 2009; CD000126.Google Scholar5 GALA Trial Collaborative Group. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet. 2008; 372: 2132–2142.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Lobo M, Mourão J and Afonso G (2015) Endarterectomia carotídea: revisão de 10 anos de prática de anestesia geral e locorregional num hospital terciário em Portugal, Brazilian Journal of Anesthesiology, 10.1016/j.bjan.2014.03.010, 65:4, (249-254), Online publication date: 1-Jul-2015. Lobo M, Mourão J and Afonso G (2015) Endarterectomía carotídea: revisión de 10 años de práctica de la anestesia general y locorregional en un hospital terciario en Portugal, Brazilian Journal of Anesthesiology (Edicion en Espanol), 10.1016/j.bjanes.2014.03.012, 65:4, (249-254), Online publication date: 1-Jul-2015. Lobo M, Mourão J and Afonso G (2015) Carotid endarterectomy: review of 10 years of practice of general and locoregional anesthesia in a tertiary care hospital in Portugal, Brazilian Journal of Anesthesiology (English Edition), 10.1016/j.bjane.2014.03.011, 65:4, (249-254), Online publication date: 1-Jul-2015. Keith Ozaki C (2014) In brief, Current Problems in Surgery, 10.1067/j.cpsurg.2014.02.003, 51:5, (194-196), Online publication date: 1-May-2014. Keith Ozaki C, Sobieszczyk P, Ho K, McPhee J and Gravereaux E (2014) Evidence-based carotid artery–based interventions for stroke risk reduction, Current Problems in Surgery, 10.1067/j.cpsurg.2014.01.002, 51:5, (198-242), Online publication date: 1-May-2014. Ciccozzi A, Angeletti C, Guetti C, Pergolizzi J, Angeletti P, Mariani R and Marinangeli F (2014) Regional anaesthesia techniques for carotid surgery: the state of art, Journal of Ultrasound, 10.1007/s40477-014-0094-5, 17:3, (175-183), Online publication date: 1-Sep-2014. Unic-Stojanovic D, Babic S and Neskovic V (2013) General Versus Regional Anesthesia for Carotid Endarterectomy, Journal of Cardiothoracic and Vascular Anesthesia, 10.1053/j.jvca.2012.09.021, 27:6, (1379-1383), Online publication date: 1-Dec-2013. Gürer O, Yapıcı F, Yapıcı N, Özler A and Işık Ö (2012) Comparison Between Local and General Anesthesia for Carotid Endarterectomy: Early and Late Results, Vascular and Endovascular Surgery, 10.1177/1538574411431345, 46:2, (131-138), Online publication date: 1-Feb-2012. Rerkasem K and Shearman C (2012) Anaesthesia during Carotid Endarterectomy and Urinary Neopterin, ISRN Stroke, 10.5402/2012/562184, 2012, (1-4), Online publication date: 17-Oct-2012. Eckstein H, Assadian A, Kühnl A and Berger H (2012) Supraaortale Gefäße Operative und interventionelle Gefäßmedizin, 10.1007/978-3-642-01709-4_20, (381-421), . Attigah N, Kutter J, Demirel S, Hakimi M, Hinz U, Motsch J and Böckler D (2011) Assessment of Patients' Satisfaction in Carotid Surgery under Local Anaesthesia by Psychometrical Testing – A Prospective Cohort Study, European Journal of Vascular and Endovascular Surgery, 10.1016/j.ejvs.2010.08.020, 41:1, (76-82), Online publication date: 1-Jan-2011. Baldinelli F, Pedrazzoli R, Ebner H and Auricchio F (2010) Asleep-Awake-Asleep Technique During Carotid Endarterectomy: A Case Series, Journal of Cardiothoracic and Vascular Anesthesia, 10.1053/j.jvca.2010.02.009, 24:4, (550-554), Online publication date: 1-Aug-2010. October 2009Vol 40, Issue 10 Advertisement Article InformationMetrics https://doi.org/10.1161/STROKEAHA.109.558288 Manuscript receivedMay 19, 2009Manuscript acceptedMay 25, 2009Originally publishedAugust 20, 2009 PDF download Advertisement
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