A Systematic Review and Meta-Analysis on Perioperative Cerebral and Hemodynamic Monitoring Methods during Carotid Endarterectomy

To compare outcomes between different strategies of perioperative cerebral and hemodynamic monitoring during carotid endarterectomy. MEDLINE, EMBASE, CINAHL, and Cochrane CENTRAL databases were searched. This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and prospectively registered in the international prospective register of systematic reviews (CRD42021241891). The Grading of Recommendations, Assessment, Development and Evaluation approach was used to describe the methodological quality of the studies and certainty of the evidence. The primary outcome was 30-day stroke rate. Secondary outcomes measures are 30-day ipsilateral stroke, 30-day mortality, shunt rate, and complication rates. The search identified 3,460 articles. Seventeen randomized controlled trials (RCTs), three prospective observational studies and seven registries were included, reporting on 236,983 patients. The overall pooled 30-day stroke rate is 1.8% (95% CI 1.4–2.2%), ranging from 0 to 12.6%. In RCT's the pooled 30-day stroke rate is 2.7% (95% CI 1.6–3.7%) compared to 1.3% (95% CI 0.8–1.8%) in the registries. The overall stroke risk decreased from 3.7% before the year 2000 to 1.6% after 2000. No significant differences could be identified between different monitoring and shunting strategies, although a trend to higher stroke rates in routine no shunting arms of RCTs was observed. Overall, 30-day mortality, myocardial infarction and nerve injury rates are 0.6% (95% CI 0.4–0.8), 0.8% (95% CI 0.6–1.0) and 1.3% (95% CI 0.4–2.2), respectively. No significant differences between the compared shunting and monitoring strategies are found. However, routine no shunting is not recommended. The available data are too limited to prefer 1 method of neuromonitoring over another method when selective shunting is applied.