General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial

BACKGROUND The effect of carotid endarterectomy in lowering the risk of stroke ipsilateral to severe atherosclerotic carotid-artery stenosis is offset by complications during or soon after surgery. We compared surgery under general anaesthesia with that under local anaesthesia because prediction and avoidance of perioperative strokes might be easier under local anaesthesia than under general anaesthesia. METHODS We undertook a parallel group, multicentre, randomised controlled trial of 3526 patients with symptomatic or asymptomatic carotid stenosis from 95 centres in 24 countries. Participants were randomly assigned to surgery under general (n=1753) or local (n=1773) anaesthesia between June, 1999 and October, 2007. The primary outcome was the proportion of patients with stroke (including retinal infarction), myocardial infarction, or death between randomisation and 30 days after surgery. Analysis was by intention to treat. The trial is registered with Current Control Trials number ISRCTN00525237. FINDINGS A primary outcome occurred in 84 (4.8%) patients assigned to surgery under general anaesthesia and 80 (4.5%) of those assigned to surgery under local anaesthesia; three events per 1000 treated were prevented with local anaesthesia (95% CI -11 to 17; risk ratio [RR] 0.94 [95% CI 0.70 to 1.27]). The two groups did not significantly differ for quality of life, length of hospital stay, or the primary outcome in the prespecified subgroups of age, contralateral carotid occlusion, and baseline surgical risk. INTERPRETATION We have not shown a definite difference in outcomes between general and local anaesthesia for carotid surgery. The anaesthetist and surgeon, in consultation with the patient, should decide which anaesthetic technique to use on an individual basis. FUNDING The Health Foundation (UK) and European Society of Vascular Surgery.

[1]  A Halliday MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group : Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms : randomized controlled trial , 2004 .

[2]  J. Desborough The stress response to trauma and surgery. , 2000, British journal of anaesthesia.

[3]  P. Myles,et al.  Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial , 2002, The Lancet.

[4]  J. Pandit,et al.  Superficial or deep cervical plexus block for carotid endarterectomy: a systematic review of complications. , 2007, British journal of anaesthesia.

[5]  M. Eliasziw,et al.  Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis , 2003, The Lancet.

[6]  P. Ševčík,et al.  Regional anaesthesia for carotid endarterectomy: an audit over 10 years. , 2007, British journal of anaesthesia.

[7]  P. Rothwell,et al.  Patch angioplasty versus primary closure for carotid endarterectomy. , 2009, The Cochrane database of systematic reviews.

[8]  S. Lewis,et al.  GALA: an international multicentre randomised trial comparing general anaesthesia versus local anaesthesia for carotid surgery , 2008, Trials.

[9]  R. Peto,et al.  Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial , 2004, The Lancet.

[10]  Anthony Rodgers,et al.  Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials , 2000, BMJ : British Medical Journal.

[11]  N. Dearden,et al.  The differing effects of regional and general anaesthesia on cerebral metabolism during carotid endarterectomy. , 1996, European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery.

[12]  C. Warlow,et al.  Prediction of benefit from carotid endar terectomy in individual patients: a risk-modelling study , 1999, The Lancet.

[13]  M. Eliasziw,et al.  Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery , 2004, The Lancet.