Department of Physical Therapy, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand.
Environmental - Occupational Health Sciences and Non Communicable Diseases Research Group, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand.
Cochrane Database Syst Rev. 2022 Jun 22;6(6):CD000190. doi: 10.1002/14651858.CD000190.pub4.
Temporary interruption of cerebral blood flow during carotid endarterectomy can be avoided by using a shunt across the clamped section of the carotid artery. The shunt may improve the outcome. This is an update of a Cochrane review originally published in 1996 and previously updated in 2002, 2009, and 2014.
To assess the effect of routine versus selective or no shunting, and to assess the best method for selective shunting on death, stroke, and other complications in people undergoing carotid endarterectomy under general anaesthesia.
We searched the Cochrane Stroke Group Trials Register (last searched April 2021), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2021, Issue 4), MEDLINE (1966 to April 2021), Embase (1980 to April 2021), and the Science Citation Index Expanded (SCI-EXPANDED) (1980 to April 2021). We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform, and handsearched relevant journals, conference proceedings, and reference lists.
Randomised and quasi-randomised trials of routine shunting compared with no shunting or selective shunting, and trials that compared different shunting policies in people undergoing carotid endarterectomy.
Three independent review authors performed data extraction, selection, and analysis. A pooled Peto odds ratio (OR) and 95% confidence interval (CI) were computed for all outcomes of interest. Best and worse case scenarios were also calculated in case of unavailable data. Two authors independently assessed risk of bias, and quality of evidence using GRADE.
No new trials were found for this updated review. Thus, six trials involving 1270 participants are included in this latest review: three trials involving 686 participants compared routine shunting with no shunting, one trial involving 200 participants compared routine shunting with selective shunting, one trial involving 253 participants compared selective shunting with and without near-infrared refractory spectroscopy monitoring, and the other trial involving 131 participants compared shunting with a combination of electroencephalographic and carotid pressure measurement with shunting by carotid pressure measurement alone. Only three trials comparing routine shunting and no shunting were eligible for meta-analysis. Major findings of this comparison found that the routine shunting had less risk of stroke-related death within 30 days of surgery (best case) than no shunting (Peto odds ratio (OR) 0.13, 95% confidence interval (CI) 0.02 to 0.96, I not applicable, P = 0.05, low-quality evidence), the routine shunting group had a lower stroke rate within 24 hours of surgery (Peto odds ratio (OR) 0.15, 95% CI 0.03 to 0.78, I = not applicable, P = 0.02, low-quality evidence), and ipsilateral stroke within 30 days of surgery (best case) (Peto OR 0.41, 95% CI 0.18 to 0.97, I = 52%, P = 0.04, low-quality evidence) than the no shunting group. No difference was found between the groups in terms of postoperative neurological deficit between selective shunting with and without near-infrared refractory spectroscopy monitoring. However, this analysis was inadequately powered to reliably detect the effect. There was no difference between the risk of ipsilateral stroke in participants selected for shunting with the combination of electroencephalographic and carotid pressure assessment compared with 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 when performed under general anaesthesia. Large-scale randomised trials of routine shunting versus selective shunting are required. No method of monitoring in selective shunting has been shown to produce better outcomes.
在颈动脉内膜切除术期间，通过在夹闭的颈动脉段放置分流器，可以避免暂时中断脑血流。分流器可能会改善结果。这是对 1996 年最初发表的 Cochrane 综述的更新，此前分别于 2002 年、2009 年和 2014 年进行了更新。
评估常规与选择性或不使用分流器，以及评估选择性分流器的最佳方法对全身麻醉下接受颈动脉内膜切除术的患者的死亡、卒中和其他并发症的影响。
我们检索了 Cochrane 卒中组试验注册库（最近检索日期为 2021 年 4 月）、Cochrane 中心对照试验注册库（The Cochrane Library 2021, Issue 4）、MEDLINE（1966 年至 2021 年 4 月）、Embase（1980 年至 2021 年 4 月）和科学引文索引扩展版（SCI-EXPANDED）（1980 年至 2021 年 4 月）。我们还检索了 ClinicalTrials.gov 和世界卫生组织国际临床试验注册平台，并手检了相关杂志、会议记录和参考文献列表。
比较常规分流与无分流或选择性分流的随机和半随机试验，以及比较颈动脉内膜切除术患者不同分流策略的试验。
三名独立的综述作者进行了数据提取、选择和分析。使用 Peto 比值比（OR）和 95%置信区间（CI）计算了所有感兴趣结局的汇总结果。在无法获得数据的情况下，还计算了最佳和最差情况的结果。两名作者独立评估了偏倚风险和使用 GRADE 评估证据质量。
本更新综述未发现新的试验。因此，纳入了六项涉及 1270 名参与者的试验：三项试验涉及 686 名参与者，比较了常规分流与无分流，一项试验涉及 200 名参与者，比较了常规分流与选择性分流，一项试验涉及 253 名参与者，比较了选择性分流与近红外反射光谱监测和无监测，另一项试验涉及 131 名参与者，比较了分流与脑电图和颈动脉压力测量的组合与单独颈动脉压力测量的分流。只有三项比较常规分流和无分流的试验符合荟萃分析的条件。这一比较的主要发现是，常规分流术与无分流术相比，在手术后 30 天内的卒中相关死亡率较低（最佳情况）（Peto 比值比（OR）0.13，95%置信区间（CI）0.02 至 0.96，I 不适用，P = 0.05，低质量证据），常规分流术组在手术后 24 小时内的卒中发生率较低（Peto 比值比（OR）0.15，95%置信区间（CI）0.03 至 0.78，I 不适用，P = 0.02，低质量证据），且在手术后 30 天内同侧卒中的发生率较低（最佳情况）（Peto OR 0.41，95% CI 0.18 至 0.97，I = 52%，P = 0.04，低质量证据），无分流术组（低质量证据）。在选择性分流术与近红外反射光谱监测或不监测之间，术后神经功能缺损的风险没有差异。然而，这一分析的效力不足，无法可靠地检测到效果。与单独使用压力评估相比，使用脑电图和颈动脉压力评估组合进行分流的患者发生同侧卒中的风险没有差异，尽管数据仍然有限。
本综述得出的结论是，现有的数据过于有限，无法支持或反驳全身麻醉下颈动脉内膜切除术时常规或选择性分流的使用。需要进行大规模的随机试验，比较常规分流与选择性分流。目前还没有一种监测方法被证明可以产生更好的结果。
