Meta‐analysis and trial sequential analysis of local vs. general anaesthesia for carotid endarterectomy

Abstract

Controversy exists regarding the best choice of anaesthesia for carotid endarterectomy. We aimed to evaluate the peri-operative outcomes of local vs. general anaesthesia for carotid endarterectomy. We conducted a systematic search of electronic information sources and applied a combination of free text and controlled vocabulary searches adapted to thesaurus headings, search operators and limits in each of the electronic databases. We defined peri-operative stroke, transient ischaemic attack, mortality and myocardial infarction as the primary outcome measures. We identified 12 randomised controlled trials and 21 observational studies reporting a total of 58,212 patients undergoing carotid endarterectomy under local or general anaesthesia. Analysis of observational studies demonstrated that local anaesthesia was associated with a significantly lower incidence of stroke (odds ratio (OR (95% CI) 0.66 (0.55-0.80), p < 0.0001), transient ischaemic attack (0.52 (0.38-0.70), p < 0.0001), myocardial infarction (0.55 (0.41-0.75), p = 0.0002) and mortality (0.72 (0.56-0.94), p = 0.01) compared with general anaesthesia. Analysis of randomised controlled trials did not find a significant difference in the risk of stroke (0.92 (0.67-1.28), p = 0.63), transient ischaemic attack (2.20 (0.48-10.03), p = 0.31), myocardial infarction (1.25 (0.57-2.72), p = 0.58) or mortality (0.61 (0.35-1.05), p = 0.07) between local and general anaesthesia. On trial sequential analysis of the randomised trials, the Z-curve did not cross the α-spending boundaries or futility boundaries for stroke, mortality and transient ischaemic attack, suggesting that more trials are needed to reach conclusive results. Our meta-analysis of observational studies suggests that local anaesthesia for carotid endarterectomy may be associated with lower peri-operative morbidity and mortality compared with general anaesthesia. Although randomised studies have not confirmed any advantage for local anaesthesia, this may be due to a lack of pooled statistical power in these trials.

General Anesthesia Versus Local Anesthesia in Carotid Endarterectomy: A Systematic Review and Meta-Analysis

“…Three major meta-analyses have been performed in an effort to resolve this issue. [43][44][45] Two of these studies 43,45 concluded that LA was associated with significantly lower stroke and mortality rates, but the remaining study by Vaniyapong et al, 44 which included only RCTs, found no significant difference in outcomes between LA and GA. This current study, with a total sample size of 152,376, represented a much bigger population than any of the previous meta-analyses.…”

“…This goes along with findings from previous meta-analyses that included nonrandomized studies. 43,45 However, the nonsignificant difference in the RCT subgroup analysis suggested possible bias in nonrandomized studies that were eliminated in the RCTs. Although DM and hypertension were well-established cardiovascular risk factors in general a prospective cohort study has failed to demonstrate any statistically significant differences between the morbidities in patients with or without these risk factors, 46 implying that this is less likely to be a confounder in this study.…”

“…These findings have been echoed by other previously published meta-analyses. 43,45 Considering that LA was associated with lower rates of vascular complication, postoperative stroke, and cardiac complications and shorter mean length of stay in the hospital and intensive care unit, the finding regarding the mortality rate should not be surprising. The significantly shorter length of stay in the LA group likely was due to the higher proportion of patients in the GA group having diabetes and postoperative complications, both of which have been demonstrated to be risk factors for prolonged length of stay.…”

Perioperativer Schlaganfall

“…Der Vergleich von Lokal-und Allgemeinanästhesie während offener Karotischirurgie ergab keinen eindeutigen Vorteil vonLokalanästhesie hinsichtlichdes Auftretens postoperativer zerebrovaskulärer Ereignisse [55][56][57]. Unterschiedliche Anästhesieverfahren, u. a. Analgosedierung, Spinal-und Epiduralanästhesie, wurden mit einer Allgemeinanästhesie während der endovaskulären Versorgung von abdominalen Aortenaneurysmen in prospektiven Beobachtungsstudien verglichen.…”

Carotid endarterectomy under local anesthesia: An institutional report of experience

“…[4] Although not yet proven in randomized clinical trials, CEA under local anesthesia has been suggested to reduce perioperative morbidity and mortality in the latest reports. [5] In this study, we present our personal singlesurgeon experiences regarding CEA procedures performed under local anesthesia.…”