Rerkasem Kittipan, Rothwell Peter M
Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand, 50200.
Cochrane Database Syst Rev. 2009 Oct 7(4):CD000190. doi: 10.1002/14651858.CD000190.pub2.
Temporary interruption of cerebral blood flow during carotid endarterectomy can be avoided by using a shunt across the clamped section of the carotid artery. This may improve outcome. This is an update of a Cochrane Review originally published in 1996 and previously updated in 2001.
To assess the effect of routine versus selective, or never, shunting during carotid endarterectomy, and to assess the best method for selecting patients for shunting.
We searched the Cochrane Stroke Group Trials Register (last searched September 2008), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2009), MEDLINE (1966 to November 2008), EMBASE (1980 to November 2008) and Index to Scientific and Technical Proceedings (1980 to November 2008). We handsearched journals and conference proceedings, checked reference lists, and contacted experts in the field.
Randomised and quasi-randomised trials of routine shunting compared with no shunting or selective shunting, and trials that compared different shunting policies in patients undergoing carotid endarterectomy.
Two review authors independently performed the searches and applied the inclusion criteria. We identified one new relevant randomised controlled trial.
We included four trials in the review: three trials involving 686 patients compared routine shunting with no shunting; the other trial involving 131 patients compared shunting with a combination of electroencephalographic and carotid pressure measurement with shunting by carotid pressure measurement alone. Allocation was adequately concealed in one trial, and one trial was quasi-randomised. Analysis was by intention-to-treat where possible. For routine versus no shunting, there was no significant difference in the rate of all stroke, ipsilateral stroke or death up to 30 days after surgery, although data were limited. There was no significant difference between the risk of ipsilateral stroke in patients selected for shunting with the combination of electroencephalographic and carotid pressure assessment compared to pressure assessment alone, although again the data were limited.
AUTHORS' CONCLUSIONS: This review concluded that the data available were too limited to either support or refute the use of routine or selective shunting in carotid endarterectomy. It was suggested that large scale randomised trials between routine shunting versus selective shunting were required. No one method of monitoring in selective shunting has been shown to produce better outcomes.
在颈动脉内膜切除术期间，通过在颈动脉夹闭段置入分流管可避免脑血流的暂时中断。这可能会改善手术效果。本综述是对一篇最初发表于1996年且曾在2001年更新过的Cochrane综述的更新。
评估在颈动脉内膜切除术中常规分流与选择性分流或不分流的效果，并评估选择分流患者的最佳方法。
我们检索了Cochrane卒中组试验注册库（最后检索时间为2008年9月）、Cochrane对照试验中央注册库（CENTRAL）（《Cochrane图书馆》，2009年第1期）、MEDLINE（1966年至2008年11月）、EMBASE（1980年至2008年11月）以及《科技会议录索引》（1980年至2008年11月）。我们手工检索了期刊和会议论文集，检查了参考文献列表，并联系了该领域的专家。
将常规分流与不分流或选择性分流进行比较的随机和半随机试验，以及比较接受颈动脉内膜切除术患者不同分流策略的试验。
两位综述作者独立进行检索并应用纳入标准。我们识别出一项新的相关随机对照试验。
本综述纳入了四项试验：三项试验涉及686例患者，比较了常规分流与不分流；另一项试验涉及131例患者，比较了脑电图和颈动脉压力测量联合分流与单纯颈动脉压力测量分流。在一项试验中分配方案得到了充分隐藏，且有一项试验为半随机试验。尽可能采用意向性分析。对于常规分流与不分流，术后30天内全卒中、同侧卒中和死亡发生率无显著差异，尽管数据有限。与单纯压力评估相比，脑电图和颈动脉压力评估联合选择分流患者的同侧卒中风险无显著差异，尽管同样数据有限。
本综述得出结论，现有数据过于有限，无法支持或反驳在颈动脉内膜切除术中使用常规或选择性分流。建议进行常规分流与选择性分流之间的大规模随机试验。在选择性分流中，尚未证明哪种监测方法能产生更好的结果。
