Local versus general anaesthesia in carotid endarterectomy: A systematic review of the evidence

Objective: To determine whether carotid endarterectomy under local anaesthesia is safer and as effective as under general anaesthesia. Design: Systematic review of the randomised and non-randomised studies. Materials: Studies were identified from the Cochrane Stroke Group's database plus additional hand searching and electronic searching. Methods: Two authors independently selected studies for inclusion and extracted details of trial quality and data on death, any stroke, myocardial infarction and other operative complications. Meta-analysis was performed using the Peto method. Results: There were 17 non-randomised studies (about 5970 patients) and only three randomised studies (143 patients). The non-randomised studies suggested that the use of local anaesthesia may be associated with clinically important reductions (approximately 50%) in the odds of stroke, stroke or death, myocardial infarction and pulmonary complications during the perioperative period, and with reductions in hospital stay. There were far too little data from the randomised trials to confirm or refute these findings: only one death and seven strokes were reported. Conclusions Non-randomised studies suggest potentially important benefits from performing carotid endarterectomy under local anaesthesia. However, these studies were seriously flawed and can only be hypothesis generating. The results must be confirmed in large well-designed randomised trials before any recommendations on the use of local anaesthetic can be made.