Advantages of Selective Use of Intraluminal Shunt in Carotid Endarterectomy: a Study of 122 Cases

Abstract

Objectives:To assess the advantage of selective use of shunt in carotid endarterectomy (CEA) under local anesthesia. Materials and Methods: A total of 122 consecutive patients fulfilling international guidelines were included. Shunt was used selectively only in cases of bilateral severe carotid artery occlusive disease or in those patients who developed neurological symptoms on clamping of carotid artery. Follow up was done weekly for one month; then every month for 3 months; and then every 3 months for a year. Results: Shunt was used only in 5% (n = 6) patients. Of these, 2.5% (n = 3) patients were those who developed neurological symptoms on clamping the internal carotid and deployment of shunt resulted in complete resolution of symptoms. 2.5% (n = 3) had severe bilateral carotid stenosis and shunt was deployed. One of these patients developed stroke which was permanent. There was no mortality. The mean procedure time was 170 min in patients in whom shunt was used, when compared with 100 min in patients without shunt (P = 0.003). Conclusion: Use of shunt in carotid endarterectomy under local anesthesia as selective policy has an advantage in terms of cost effectiveness, operation time and prevention of potential complications.Keywords: shunt, carotid artery, surgery, local anesthesia, advantage in asymptomatic disease and higher in symptomatic patients. 1) The major risk factors are advanced age, male gender, smoking and diabetes mellitis. 2,3) To make stroke free survival carotid endarterectomy (CEA) is performed in asymptomatic and symptomatic patients with ≥70% and ≥50% stenosis of internal carotid artery respectively. 4,5) Perioperative strokes mostly are due to ipsilateral diseased carotid but some may be due to carotid artery clamping resulting in brain ischemia. 4) The duration of interrupted blood flow can be reduced by using a shunt to fulfill circulatory needs of the brain. CEA can be performed under local or general anesthesia with routine or selective use of shunt. 4,5) Potential disadvantage of using shunt during CEA include increase in operation time, dislodgement, bleeding, dissection of artery, tear in the artery wall, air or plaque embolism and increased local complications like nerve injury, infection, hematoma and long term stenosis. 6) However, reliable data is limited. 7) Selective use of shunt in cases of bilateral severe carotid artery occlusive disease and in those cases which developed neurological symptoms on clamping of carotid artery, can reduce shunt induced complications. 7) Keeping in view these international reviews and scarcity of guidelines in our national literature, we performed this study in our department with selective use of shunt to assess shunt related perioperative morbidity. Materials and MethodsAll consecutive patients reporting to the department of Vascular Surgery in Combined Military Hospital Lahore between January 2012 to January 2015; with documented narrowing of carotid artery occlusive disease, were included in this study. Of these, patients who were symptoma...

Ultrasound-guided superficial cervical plexus block under dexmedetomidine sedation versus general anesthesia for carotid endarterectomy: a retrospective pilot study

“…In our study, shunts were used in 93.8% patients receiving GA and 18.5% in patients with RA. Although the use of a shunt is common practice and should protect the brain from stroke [26,27], intraoperative shunt placement is a strong predictor of perioperative strokes [28].…”

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“…In addition, improperly placed shunts may cause embolisms. M. Jamil et al showed that routine shunt use did not affect perioperative results [12]. On the other hand, there are studies indicating that selective and routine shunt use reduce the incidence of stroke [13,14].…”

Comparison of Eversion Carotid Endarterectomy and Patch Carotid Endarterectomy: A Retrospective Study of 6 Years of Experience

“…The use of a shunt has many potential disadvantages, including dislodgement and air or plaque embolism, requiring extra time for insertion and removal, longer arteriotomy, and poor cost effectiveness [ 14 ]. One study included 122 consecutive patients with a mean procedure time of 170 min in patients in whom a shunt was used compared with 100 min in patients without a shunt (P=0.003) [ 15 ]. Another study of 59 patients showed that conventional use of a carotid shunt tube in carotid endarterectomy (CEA) for extracranial carotid stenosis treatment does not reduce the risk of perioperative complications [ 16 ].…”