There is More to Preventing Stroke After Carotid Surgery than Shunt and Patch Debates

Summary Despite level I evidence that carotid endarterectomy (CEA) confers significant benefit over ‘best medical therapy’, the paradox remains that the very operation undertaken to prevent stroke (in the long-term) is associated with a small, but important risk of stroke in the peri-operative period. This paradox has, of course, been recognised for more than 50 years. However, the debate as to how stroke and other cardiovascular complications might be prevented following CEA remains largely unresolved and has been inappropriately dominated by ‘single-issue’ subjects. These include; choice of anaesthesia, traditional versus eversion endarterectomy, dose of aspirin, shunt usage, shunt thresholds, patching, tacking sutures, peri-operative monitoring, sinus nerve blockade and heparin reversal. Many of these issues are now largely irrelevant, already resolved or simply unresolvable. Their enduring persistence has, however, compromised the evolution of newer and more novel strategies for reducing peri-operative cardiovascular morbidity and mortality. The ‘hottest’ single-issue subject of the moment is the role of locoregional anaesthesia (LRA) versus general anaesthesia. The literature abounds with claims that CEA under LRA confers significant benefit, but a 2004 meta-analysis of the seven available randomised trials continues to show no significant