Environmental - Occupational Health Sciences and Non Communicable Diseases Center of Excellence, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand.
Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Thammasat University (Rangsit Campus), Pathum Thani, Thailand.
Cochrane Database Syst Rev. 2021 Oct 13;10(10):CD000126. doi: 10.1002/14651858.CD000126.pub5.
Carotid endarterectomy may significantly reduce the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks that may be minimised by performing the operation under local rather than general anaesthetics. This is an update of a Cochrane Review first published in 1996, and previously updated in 2004, 2008, and 2013.
To determine whether carotid endarterectomy under local anaesthetic: 1) reduces the risk of perioperative stroke and death compared with general anaesthetic; 2) reduces the complication rate (other than stroke) following carotid endarterectomy; and 3) is acceptable to individuals and surgeons.
We searched CENTRAL, MEDLINE, Embase, and two trials registers (to February 2021). We also reviewed reference lists of articles identified.
Randomised controlled trials (RCTs) comparing the use of local anaesthetics to general anaesthetics for people having carotid endarterectomy were eligible.
Three review authors independently extracted data, assessed risk of bias, and evaluated quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) tool. We calculated a pooled Peto odds ratio (OR) and corresponding 95% confidence interval (CI) for the following outcomes that occurred within 30 days of surgery: stroke, death, ipsilateral stroke, stroke or death, myocardial infarction, local haemorrhage, and arteries shunted.
We included 16 RCTs involving 4839 participants, of which 3526 were obtained from the single largest trial (GALA). The main findings from our meta-analysis showed that, within 30 days of operation, neither incidence of stroke nor death were significantly different between local and general anaesthesia. Of these, the incidence of stroke in the local and general anaesthesia groups was 3.2% and 3.5%, respectively (Peto odds ratio (OR) 0.91, 95% confidence interval (CI) 0.66 to 1.26; P = 0.58; 13 studies, 4663 participants; low-quality evidence). The rate of ipsilateral stroke under both types of anaesthesia was 3.1% (Peto OR 1.03, 95% CI 0.71 to 1.48; P = 0.89; 2 studies, 3733 participants; low-quality evidence). The incidence of stroke or death in the local anaesthesia group was 3.5%, while stroke or death incidence was 4.1% in the general anaesthesia group (Peto OR 0.85, 95% CI 0.62 to 1.16; P = 0.31; 11 studies, 4391 participants; low-quality evidence). A lower rate of death was observed in the local anaesthetic group but evidence was of low quality (Peto OR 0.61, 95% CI 0.35 to 1.06; P = 0.08; 12 studies, 4421 participants).
AUTHORS' CONCLUSIONS: The incidence of stroke and death were not convincingly different between local and general anaesthesia for people undergoing carotid endarterectomy. The current evidence supports the choice of either approach. Further high-quality studies are still needed as the evidence is of limited reliability.
颈动脉内膜切除术可显著降低近期有症状、严重颈动脉狭窄患者发生中风的风险。然而，围手术期存在显著风险，可以通过局部麻醉而不是全身麻醉来降低这些风险。这是一篇发表于 1996 年的 Cochrane 综述的更新内容，之前分别于 2004 年、2008 年和 2013 年进行了更新。
确定在局部麻醉下进行颈动脉内膜切除术是否：1）降低围手术期中风和死亡的风险，与全身麻醉相比；2）降低颈动脉内膜切除术后的并发症发生率（除中风外）；以及 3）个体和外科医生可以接受。
我们检索了 CENTRAL、MEDLINE、Embase 和两个试验登记处（截至 2021 年 2 月）。我们还审查了从已确定的文章中检索到的参考文献列表。
符合条件的随机对照试验（RCT）比较了在进行颈动脉内膜切除术时使用局部麻醉剂与全身麻醉剂的情况。
三名综述作者独立提取数据，使用 Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) 工具评估风险偏倚和证据质量。我们计算了以下 30 天内发生的结局的汇总 Peto 比值比（OR）和相应的 95%置信区间（CI）：中风、死亡、同侧中风、中风或死亡、心肌梗死、局部出血和动脉分流。
我们纳入了 16 项 RCT，涉及 4839 名参与者，其中 3526 名来自规模最大的单一试验（GALA）。我们的荟萃分析的主要发现表明，在手术 30 天内，局部麻醉和全身麻醉组的中风发生率和死亡率均无显著差异。其中，局部麻醉组和全身麻醉组的中风发生率分别为 3.2%和 3.5%（Peto OR 0.91，95%置信区间 0.66 至 1.26；P = 0.58；13 项研究，4663 名参与者；低质量证据）。两种麻醉类型下同侧中风的发生率均为 3.1%（Peto OR 1.03，95%置信区间 0.71 至 1.48；P = 0.89；2 项研究，3733 名参与者；低质量证据）。局部麻醉组中风或死亡的发生率为 3.5%，而全身麻醉组中风或死亡的发生率为 4.1%（Peto OR 0.85，95%置信区间 0.62 至 1.16；P = 0.31；11 项研究，4391 名参与者；低质量证据）。局部麻醉组的死亡率较低，但证据质量较低（Peto OR 0.61，95%置信区间 0.35 至 1.06；P = 0.08；12 项研究，4421 名参与者）。
在接受颈动脉内膜切除术的人群中，局部麻醉和全身麻醉的中风和死亡率没有明显差异。目前的证据支持两种方法的选择。由于证据的可靠性有限，仍需要更多高质量的研究。
