General versus local anesthesia for carotid endarterectomy: the West Australian experience

CHIRURGIA 423 cation rate for an individual center or surgeon determines the efficacy of preventing stroke, particularly in asymptomatic patients.6 The GALA (general anesthesia [GA] versus local anesthesia [LA] in carotid surgery) trial aimed to determine if local anesthesia in carotid surgery would have a beneficial effect on outcomes of carotid endarterectomy.7 Studies prior to GALA suggested that LA may be beneficial in terms of cerebral metabolism during CEA when compared to GA.8-10 However, the GALA trial demonstrated no significant differences in primary outcomes between LA and GA.6 Analysis of pre-specified subgroups similarly did not reveal any significant differences. Whilst there was a suggestion that patients with significant contralateral disease may have benefited from LA, the difference was not statistically significant. In terms of local applicability of the study results, an analysis of United Kingdom versus nonUnited Kingdom outcomes did not demonstrate any significant differences in outcomes, however significant differences in the CEA procedure were reported.11 Ipsilateral carotid restenosis and contralateral disease progression after CEA requiring intervention has been previously reported (REF). The Asymptomatic Carotid Atherosclerotic Study (ACAS) follow up demonstrated an early (3-18 months) restenosis rate of 7.6%, where restenosis was defined as a Doppler determined diameter reduction of 60%.12 Other studies similarly demonstrated that 6-14% of patients developed restenosis when defined as a Doppler reduction of 50% accompanied by neurological events in 1-5% of cases.13 Using life table methods DeGroote et al., reported that the probability of developing carotid restenosis in the long term (defined as 7 years, with stenosis >50%) was as high as 32%.14 Carotid restenosis and contralateral disease progression in the GALA trial have not been reported. 1Department of Vascular Surgery Royal Perth Hospital, Perth, Australia 2School of Surgery University of Western Australia, Perth, Western Australia 3School of Medicine and Pharmacology University of Western Australia, Perth, Western Australia CHIRURGIA 2012;25:423-8