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

Kittipan Rerkasem; Peter M Rothwell

doi:10.1002/14651858.CD000190.pub2

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Analysis 1.1

Comparison 1 Shunting (routine or selective) versus no shunting, Outcome 1 Death from all causes within 30 days of surgery.

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Analysis 1.2

Comparison 1 Shunting (routine or selective) versus no shunting, Outcome 2 Stroke‐related death within 30 days of surgery (best case).

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Analysis 1.3

Comparison 1 Shunting (routine or selective) versus no shunting, Outcome 3 Stroke‐related death within 30 days of surgery (worst case).

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Analysis 1.4

Comparison 1 Shunting (routine or selective) versus no shunting, Outcome 4 Any stroke during surgery (best case).

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Analysis 1.5

Comparison 1 Shunting (routine or selective) versus no shunting, Outcome 5 Any stroke during surgery (worst case).

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Analysis 1.6

Comparison 1 Shunting (routine or selective) versus no shunting, Outcome 6 Any stroke within 24 hours of surgery.

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Analysis 1.7

Comparison 1 Shunting (routine or selective) versus no shunting, Outcome 7 Any stroke within 30 days of surgery.

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Analysis 1.8

Comparison 1 Shunting (routine or selective) versus no shunting, Outcome 8 Ipsilateral stroke during surgery (best case).

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Analysis 1.9

Comparison 1 Shunting (routine or selective) versus no shunting, Outcome 9 Ipsilateral stroke during surgery (worst case).

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Analysis 1.10

Comparison 1 Shunting (routine or selective) versus no shunting, Outcome 10 Ipsilateral stroke within 30 days of surgery (best case).

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Analysis 1.11

Comparison 1 Shunting (routine or selective) versus no shunting, Outcome 11 Ipsilateral stroke within 30 days of surgery (worst case).

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Analysis 1.12

Comparison 1 Shunting (routine or selective) versus no shunting, Outcome 12 Stroke or death within 30 days of surgery (best case).

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Analysis 1.13

Comparison 1 Shunting (routine or selective) versus no shunting, Outcome 13 Stroke or death within 30 days of surgery (worst case).

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Analysis 1.14

Comparison 1 Shunting (routine or selective) versus no shunting, Outcome 14 Haemorrhage from operation site.

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Analysis 1.15

Comparison 1 Shunting (routine or selective) versus no shunting, Outcome 15 Infection of operation site.

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Analysis 1.16

Comparison 1 Shunting (routine or selective) versus no shunting, Outcome 16 Nerve palsy post‐operatively.

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Analysis 2.1

Comparison 2 Different monitoring methods for selective shunting, Outcome 1 Ipsilateral stroke within 24 hours of surgery.

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Analysis 2.2

Comparison 2 Different monitoring methods for selective shunting, Outcome 2 Haemorrhage from operation site.

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Analysis 2.3

Comparison 2 Different monitoring methods for selective shunting, Outcome 3 Nerve palsy post‐operatively.

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Analysis 2.4

Comparison 2 Different monitoring methods for selective shunting, Outcome 4 Number of shunts inserted.

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Comparison 1. Shunting (routine or selective) versus no shunting

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
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]

1.1 Routine shunting versus no shunting	3	655	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.45 [0.13, 1.59]
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]

2.1 Routine shunting versus no shunting	3	655	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.13 [0.02, 0.96]
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]

3.1 Routine shunting versus no shunting	3	655	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.37 [0.05, 2.62]
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]

4.1 Routine shunting versus no shunting	3	655	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.42 [0.16, 1.07]
5 Any stroke during surgery (worst case) Show forest plot	3	655	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.32 [0.52, 3.38]

5.1 Routine shunting versus no shunting	3	655	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.32 [0.52, 3.38]
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]

6.1 Routine shunting versus no shunting	2	214	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.15 [0.03, 0.78]
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]

7.1 Routine shunting versus no shunting	3	655	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.77 [0.35, 1.69]
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]

8.1 Routine shunting versus no shunting	3	737	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.42 [0.17, 1.08]
9 Ipsilateral stroke during surgery (worst case) Show forest plot	3	737	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.32 [0.52, 3.37]

9.1 Routine shunting versus no shunting	3	737	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.32 [0.52, 3.37]
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]

10.1 Routine shunting versus no shunting	3	737	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.41 [0.18, 0.97]
11 Ipsilateral stroke within 30 days of surgery (worst case) Show forest plot	3	737	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.88 [0.38, 2.05]

11.1 Routine shunting	3	737	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.88 [0.38, 2.05]
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]

12.1 Routine shunting versus no shunting	3	655	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.62 [0.31, 1.27]
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]

13.1 Routine shunting versus no shunting	3	655	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.81 [0.40, 1.66]
14 Haemorrhage from operation site Show forest plot	2	641	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.19 [0.07, 19.47]

14.1 Routine shunting versus no shunting	2	641	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.19 [0.07, 19.47]
15 Infection of operation site Show forest plot	2	641	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.16 [0.00, 8.12]

15.1 Routine shunting versus no shunting	2	641	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.16 [0.00, 8.12]
16 Nerve palsy post‐operatively Show forest plot	1	138	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.81 [0.30, 10.82]

16.1 Routine shunting versus no shunting	1	138	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.81 [0.30, 10.82]

Comparison 1. Shunting (routine or selective) versus no shunting

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Comparison 2. Different monitoring methods for selective shunting

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Ipsilateral stroke within 24 hours of surgery Show forest plot	1	142	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.47 [0.25, 8.68]

1.1 EEG + back pressure versus back pressure	1	142	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.47 [0.25, 8.68]
2 Haemorrhage from operation site Show forest plot	1	142	Peto Odds Ratio (Peto, Fixed, 95% CI)	2.70 [0.37, 19.58]

2.1 EEG + back pressure versus back pressure	1	142	Peto Odds Ratio (Peto, Fixed, 95% CI)	2.70 [0.37, 19.58]
3 Nerve palsy post‐operatively Show forest plot	1	142	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.18 [0.35, 4.02]

3.1 EEG + back pressure versus back pressure	1	142	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.18 [0.35, 4.02]
4 Number of shunts inserted Show forest plot	1	142	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.43 [0.18, 0.98]

4.1 EEG + back pressure versus back pressure	1	142	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.43 [0.18, 0.98]

Comparison 2. Different monitoring methods for selective shunting

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