Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting)

Busaba Chuatrakoon; Sothida Nantakool; Amaraporn Rerkasem; Saritphat Orrapin; Dominic PJ Howard; Kittipan Rerkasem

doi:10.1002/14651858.CD000190.pub4

Cochrane Database of Systematic Reviews

Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting)

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DOI:

https://doi.org/10.1002/14651858.CD000190.pub4 Copy DOI

Database:

Cochrane Database of Systematic Reviews

Version published:

22 June 2022see what's new

Type:

Intervention

Stage:

Review

Cochrane Editorial Group:

Cochrane Stroke Group

Copyright:

Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

Busaba Chuatrakoon

Department of Physical Therapy, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
Sothida Nantakool

Environmental - Occupational Health Sciences and Non Communicable Diseases Research Group, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
Amaraporn Rerkasem

Environmental - Occupational Health Sciences and Non Communicable Diseases Research Group, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
Saritphat Orrapin

Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Thammasat University (Rangsit Campus), Pathum Thani, Thailand
Dominic PJ Howard

Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
Kittipan Rerkasem

Correspondence to: Environmental - Occupational Health Sciences and Non Communicable Diseases Research Group, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand

[email protected]

Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Clinical Surgical Research Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Contributions of authors

Busaba Chuatrakoon, Sothida Nantakool, Amaraporn Rerkasem, Saritphat Orrapin, Dominic PJ Howard, Kittipan Rerkasem: designing a conceptual framework; drafting, revising, and approving the final manuscript

Busaba Chuatrakoon, Sothida Nantakool, Kittipan Rerkasem: involved in data collection, data analysis, and data selection

Busaba Chuatrakoon, Amaraporn Rerkasem: assessing risk of bias

Busaba Chuatrakoon, Sothida Nantakool: evaluating quality of evidence

Sources of support

Internal sources

Faculty of Medicine, Chiang Mai University, Thailand
Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand

External sources

Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
Thailand Research Fund, Thailand

Declarations of interest

Busaba Chuatrakoon has no conflict of interest.

Sothida Nantakool has no conflict of interest.

Amaraporn Rerkasem has no conflict of interest.

Saritphat Orrapin has no conflict of interest.

Dominic PJ Howard has no conflict of interest.

Kittipan Rerkasem has no conflict of interest.

Acknowledgements

This study was partially supported by Chiang Mai University. We thank: Professor Peter Langhorne, Professor Daniel Bereczki, and Aryelly Rodriguez for commenting on this manuscript; Mr Richard Bond and Professor Peter Rothwell for their contribution to previous versions of this review.

Ongoing trials

If anyone is aware of any randomised trials that we have omitted, please contact Professor Kittipan Rerkasem.

Version history

Published

Title

Stage

Authors

Version

2022 Jun 22

Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting)

Review

Busaba Chuatrakoon, Sothida Nantakool, Amaraporn Rerkasem, Saritphat Orrapin, Dominic PJ Howard, Kittipan Rerkasem

https://doi.org/10.1002/14651858.CD000190.pub4

2014 Jun 23

Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting)

Review

Wilaiwan Chongruksut, Tanat Vaniyapong, Kittipan Rerkasem

https://doi.org/10.1002/14651858.CD000190.pub3

2009 Oct 07

Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting)

Review

Kittipan Rerkasem, Peter M Rothwell

https://doi.org/10.1002/14651858.CD000190.pub2

2009 Jul 08

Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting)

Review

Richard Bond, Kittipan Rerkasem, Peter M Rothwell

https://doi.org/10.1002/14651858.CD000190

Differences between protocol and review

In the search methods, we removed the following journals and conference proceeding as we are no longer searching them.

American Journal of Surgery
British Journal of Surgery
World Journal of Surgery
AGM of the Vascular Surgical Society (UK)
AGM of the Association of Surgeons of Great Britain and Ireland
AHA Stroke Conference
Annual Meeting of the Society for Vascular Surgery (USA)
European Stroke Conference

Details of summary of findings and assessment of the certainty of the evidence were added according to the guidance in the Cochrane Handbook for Systematic Reviews of Interventions.

Authorship was changed to BC, SN, AR, SO, DPJH, KR. Their roles are identified in the Contributions of authors section.

Keywords

MeSH

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Humans;

PICOs

Population

Intervention

Comparison

Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Figure 1

Flow diagram for updated systematic reviews

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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

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Analysis 1.1

Comparison 1: Routine shunting versus no shunting, Outcome 1: Death from all causes within 30 days of surgery

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Analysis 1.2

Comparison 1: Routine shunting versus no shunting, Outcome 2: Stroke‐related death within 30 days of surgery (best‐case)

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Analysis 1.3

Comparison 1: Routine shunting versus no shunting, Outcome 3: Stroke‐related death within 30 days of surgery (worst‐case)

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Analysis 1.4

Comparison 1: Routine shunting versus no shunting, Outcome 4: Any stroke during surgery (best‐case)

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Analysis 1.5

Comparison 1: Routine shunting versus no shunting, Outcome 5: Any stroke during surgery (worst‐case)

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Analysis 1.6

Comparison 1: Routine shunting versus no shunting, Outcome 6: Any stroke within 24 hours of surgery

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Analysis 1.7

Comparison 1: Routine shunting versus no shunting, Outcome 7: Any stroke within 30 days of surgery

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Analysis 1.8

Comparison 1: Routine shunting versus no shunting, Outcome 8: Ipsilateral stroke during surgery (best‐case)

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Analysis 1.9

Comparison 1: Routine shunting versus no shunting, Outcome 9: Ipsilateral stroke during surgery (worst‐case)

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Analysis 1.10

Comparison 1: Routine shunting versus no shunting, Outcome 10: Ipsilateral stroke within 30 days of surgery (best‐case)

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Analysis 1.11

Comparison 1: Routine shunting versus no shunting, Outcome 11: Ipsilateral stroke within 30 days of surgery (worst‐case)

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Analysis 1.12

Comparison 1: Routine shunting versus no shunting, Outcome 12: Stroke or death within 30 days of surgery (best‐case)

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Analysis 1.13

Comparison 1: Routine shunting versus no shunting, Outcome 13: Stroke or death within 30 days of surgery (worst‐case)

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Analysis 1.14

Comparison 1: Routine shunting versus no shunting, Outcome 14: Haemorrhage from operation site

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Analysis 1.15

Comparison 1: Routine shunting versus no shunting, Outcome 15: Infection of operation site

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Analysis 1.16

Comparison 1: Routine shunting versus no shunting, Outcome 16: Nerve palsy postoperatively

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Summary of findings 1. Shunting compared with no shunting for carotid endarterectomy

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)
Shunting compared with no shunting for carotid endarterectomy
Patient or population: patients with symptomatic or asymptomatic carotid disease Settings: hospital Intervention: shunting Comparison: no shunting
Outcomes	Assumed risk (no shunting)	Corresponding risk (shunting)	Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)
Death from all causes within 30 days of surgery	21 per 1000	4 per 1000 (1 to 14)	OR 0.45 (0.13 to 1.59)	655 participants (3 studies)	⊕⊕⊝⊝ low^a,b
Stroke‐related death within 30 days of surgery (best‐case)	12 per 1000	0 per 1000 (0 to 0)	OR 0.13 (0.02 to 0.96)	655 participants (3 studies)	⊕⊕⊝⊝ low^a,b
Stroke‐related death within 30 days of surgery (worst‐case)	9 per 1000	1 per 1000 (0 to 8)	OR 0.37 (0.05 to 2.62)	655 participants (3 studies)	⊕⊕⊝⊝ low^a,b
Any stroke during surgery (best‐case)	39 per 1000	7 per 1000 (3 to 17)	OR 0.42 (0.16 to 1.07)	655 participants (3 studies)	⊕⊕⊝⊝ low^a,b
Any stroke during surgery (worst‐case)	24 per 1000	41 per 1000 (16 to 105)	OR 1.32 (0.52 to 3.38)	655 participants (3 studies)	⊕⊕⊝⊝ low^a,b
Any stroke within 24 hours of surgery	53 per 1000	0 per 1000 (0 to 0)	OR 0.15 (0.03 to 0.78)	214 participants (2 studies)	⊕⊕⊝⊝ low^a,b
Any stroke within 30 days of surgery	45 per 1000	26 per 1000 (12 to 57)	OR 0.77 (0.35 to 1.69)	655 participants (3 studies)	⊕⊕⊝⊝ low^a,b
The basis for the assumed risk* is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk and the relative effect of the intervention group (and its 95% CI). CI: confidence interval; GRADE: Grades of Recommendation, Assessment, Development and Evaluation; OR: odds ratio
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
^a Downgraded by one level due to serious risk of bias as evidence used an inappropriate random sequence generation, had imbalanced surgeon assignment between groups, and had imbalance in the baseline characteristics between groups ^b Downgraded by one level due to imprecision as the evidence had a wide CI

Summary of findings 1. Shunting compared with no shunting for carotid endarterectomy

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Comparison 1. Routine shunting versus no shunting

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1.1 Death from all causes within 30 days of surgery Show forest plot	3	655	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.45 [0.13, 1.59]

1.2 Stroke‐related death within 30 days of surgery (best‐case) Show forest plot	3	655	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.13 [0.02, 0.96]

1.3 Stroke‐related death within 30 days of surgery (worst‐case) Show forest plot	3	655	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.37 [0.05, 2.62]

1.4 Any stroke during surgery (best‐case) Show forest plot	3	655	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.42 [0.16, 1.07]

1.5 Any stroke during surgery (worst‐case) Show forest plot	3	655	Odds Ratio (IV, Fixed, 95% CI)	1.71 [0.57, 5.09]

1.6 Any stroke within 24 hours of surgery Show forest plot	2	214	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.15 [0.03, 0.78]

1.7 Any stroke within 30 days of surgery Show forest plot	3	655	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.77 [0.35, 1.69]

1.8 Ipsilateral stroke during surgery (best‐case) Show forest plot	3	737	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.42 [0.17, 1.08]

1.9 Ipsilateral stroke during surgery (worst‐case) Show forest plot	3	737	Odds Ratio (IV, Fixed, 95% CI)	1.71 [0.58, 5.09]

1.10 Ipsilateral stroke within 30 days of surgery (best‐case) Show forest plot	3	737	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.41 [0.18, 0.97]

1.11 Ipsilateral stroke within 30 days of surgery (worst‐case) Show forest plot	3	737	Odds Ratio (IV, Fixed, 95% CI)	1.22 [0.46, 3.23]

1.12 Stroke or death within 30 days of surgery (best‐case) Show forest plot	3	655	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.62 [0.31, 1.27]

1.13 Stroke or death within 30 days of surgery (worst‐case) Show forest plot	3	655	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.81 [0.40, 1.66]

1.14 Haemorrhage from operation site Show forest plot	2	641	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.19 [0.07, 19.47]

1.15 Infection of operation site Show forest plot	2	641	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.16 [0.00, 8.12]

1.16 Nerve palsy postoperatively Show forest plot	1	138	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.81 [0.30, 10.82]

Comparison 1. Routine shunting versus no shunting

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Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting)

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