Anaesthesia during Carotid Endarterectomy and Urinary Neopterin

Recent systematic reviews of randomized controlled trials show that the rate of postoperative complications after carotid endarterectomy (CEA) was not significantly different between operations performed under general anesthesia (GA) or local anesthesia (LA). However, these studies were not large enough to draw meaningful conclusions about any difference in mortality. This study therefore aimed to compare a surrogate endpoint of postoperative mortality between GA and LA by using urinary neopterin. 68 consecutive patients admitted electively for CEA were studied. Urinary neopterin levels were assayed preoperatively, immediately postoperatively (PO), 4, 6, 12, and 24 hrs PO. This study compared the level of urinary neopterin between GA and LA. Of the 68 CEAs, 48 operations were performed under GA. Urinary neopterin concentration in LA group increased PO and reached a peak at 6 hrs PO. At this point, the urinary neopterin levels in the GA group (85.3？μmol/mol creatinine) were significantly lower than those under the LA group (123.4？μmol/mol creatinine) ( ). We found that the level of urinary neopterin level after operation in LA was significantly higher than those under GA. More studies are needed. 1. Introduction Atherosclerosis at the carotid bifurcation is a recognized cause of stroke, and surgical removal of the disease—carotid endarterectomy (CEA)—can decrease the chance of stroke in selected patients. Our pooled analyses of large prospective, randomized controlled trials (RCTs), that is, the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST), have clearly shown that in patients with recent symptomatic severe carotid stenosis, CEA can prevent further strokes more often than medical treatment alone [1–3]. CEA can be performed under general anesthesia (GA) or local anesthesia (LA). LA has the benefit of assessing patients’ response following clamping of the carotid artery, avoidance of inappropriate shunt insertion, and preservation of cerebral autoregulation [4]. In our previous Cochrane review, the non-RCTs showed consistently lower risks of operative death when CEA was done under LA (41 studies, 20195 CEAs, odds ratio 0.63, 95% confidence interval 0.45–0, 89, ) [5]. Our recent Cochrane review of 10 RCTs showed that there was a trend toward lower operative mortality with LA (10 RCTs, 4084 CEAs, odds ratio 0.62, 95% confidence interval 0.36–1.07, ) [6]. However, although this systematic review had some 4 thousand CEAs, the sample size was not enough to detect the effect on mortality [6]. Large