1

Eversion or standard carotid endarterectomy,

local or general anesthesia.

Does it make any difference?

Gustav Fraedrich - Innsbruck - Austria

2De Bakey ME – Ann Surg 1959;149:690-710

History of CEA & patchplasty and eversion EA

3

Carotid endarterectomy & patchplasty (CEA)

4

5

Eversion endarterectomy (EEA)

6Ricco JB – EJVES 2011;41:579

a: occlusion

b: intimal flap

c: thrombus

Routine completion angiography

ESVS guidelines 2009 - recommendation 11:Completion evaluation of the results of CEA in the form of either ultrasound or arteriography is advisable [B]

7

Restenosis after CEA

Goodney PP - JVS 2010;52:897

8

Restenosis – vein vs synthetic patch angioplasty

Bond R - JVS 2004;40:1126

9Cao P – Cochrane Stroke Group 2009 DOI 10.1002/14651858.CD001921

CEA vs EEA

Stroke & death<30 days

Ipsilat. strokefollow-up

ESVS guidelines 2009 - recommendation 9:The choice of the CEA technique depends on the experience and familiarity of the individual surgeon [A]

10

EEA vs CEA – perioperative stroke - Meta-analysis

Antonopoulos CN – EJVES 2011;doi:10.1016/j.ejvs.2011.08.012

11

Effect of technique on postoperative hypertension

Mehta M – JVS 2001;34:839 / Demirel S – JVS 2011;54:80

n=201

28 vs 10%vasodilators

n=217

24 vs 6%vasodilators

12

EEA vs CEA – restenosis - Review

Cao P – EJVES 2002;23:195

13Crawford RS - JVS 2007;46:41

EEA vs CEA - restenosis

Freedom from moderate restenosis (≤70%) Freedom from severe restenosis (>70%)

14

EEA vs CEA - risk for late occlusion - Meta-analysis

Antonopoulos CN – EJVES 2011;doi:10.1016/j.ejvs.2011.08.012

15

GALA trial – demographic and operative data

GA(n=1752)

LA(n=1771)

Age - mean ± SD 70 ± 9 69 ± 9

Male sex - no. (%) 1232 (70) 1256 (71)

Asymptomatic stenosis (%) 685 (39) 677 (38)

Conventional EA 78 % 72 %

Eversion EA 20 % 26 %

Patch plasty 50 % 42 %

Shunt 43 % 14 %

Multicenter RCT comparing General Anesthesia versus Local Anesthesia for carotid surgery

16

GA LA

Primary endpoint 4.8 % 4.5 %

risk ratio 0.94 (95% CI 0.70, 1.27)

Stroke 4.0 % 3.7 %Death 1.5 % 1.1 %Myocardial infarction (fatal & non-fatal) 0.2 % 0.5 %

GALA trial – results

No difference with regard to age, sex, preoperative symptoms, operative method – slight advantages for LA with contralateral occlusion and GA regarding early and late myocardial infarction

Primary endpoint: stroke, myocardial infarction, or death <30days

17

GA vs LA - outcome of stroke and death

Gala Trial Collaborative Group – Lancet 2008;372:2132

18Weber CF – World J Surg 2009;33:1526

GA vs LA - cognitive dysfunction

Subgroup analysis of the GALA trial – n=40

19

GA vs LA – stroke & death <30 days

ESVS guidelines 2009 - recommendation 10:Both LA and GA are safe. The anesthesist and surgeon, in consultation with the patient, should determine the method [A]

Rerkasem K – Cochrane Stroke Group 2009 DOI 10.1002/14651858.CD000126

20

Conclusions

From a scientific view it does not make any difference whether one performs eversion or standard endarterectomy (+ patch) under general or locoregional anesthesia

The choice of CEA or EEA depends on the individual surgeon and the morphology of the diseased artery

The application of GA or LA depends on the individual center experience and the patient preference

Completion evaluation is implicitly advisable