Benefit of selective shunt use during carotid endarterectomy under regional anesthesia

Abstract

Objectives Carotid cross-clamping during endarterectomy exposes the patient to intraoperative neurological deficits due to embolism or cerebral hypoperfusion. To prevent further cerebrovascular incidents, resorting to shunt is frequently recommended. However, since this method is also considered a stroke risk factor, the use is still controversial. This study aims to shed some light on the best approach regarding the use of shunt in symptomatic cerebral malperfusion after carotid artery cross-clamping. Methods From January 2012 to January 2018, 79 patients from a tertiary referral hospital who underwent carotid endarterectomy with regional anesthesia for carotid artery stenosis and manifested post-clamping neurologic deficits were prospectively gathered. Shunt use was left to the decision of the surgeon and performed in 31.6% (25) of the patients. Demographics, comorbidities, imaging tests, and clinical/intraoperative features were evaluated. For data assessment, univariate analysis was performed. Results Regarding 30-day stroke, 30-day postoperative complications (stroke, surgical hematoma, hyperperfusion syndrome), and cranial nerve injury, no significant differences were found ( P = 0.301, P = 0.460, and P = 0.301, respectively) between resource to shunt and non-shunt. Clamping and surgery times were significantly higher in the shunt group ( P < 0.001 and P = 0.0001, respectively). Conclusions Selective-shunting did not demonstrate superiority for patients who developed focal deficits regarding stroke or other postoperative complications. However, due to the limitations of this study, the benefit of shunting cannot be excluded. Further randomized trials are recommended for precise results on this matter with current sparse clinical evidence.

Regional Anesthesia for Carotid Endarterectomy in Patients with Acute Ischemic Stroke (Pilot Study)

“…Временный внутрипросветный шунт. Мнения по поводу использования ВВШ при КЭЭ противоречивы, а частота его применения у пациентов, оперированных под РА, по данным литературы, колеблется от 8,9 до 31,6% [20][21][22]. ВВШ использовали в 23,9% случаев в группе РА и в 35% случаев в группе ОА (различие недостоверно).…”

“…Снижение частоты временного шунтирования является действительно важным, так как само по себе интраоперационное применение ВВШ может являться дополнительным фактором риска ишемических церебральных осложнений [18,23]. J. M. Rocha-Neves с соавторами (2020) показали, что использование ВВШ не продемонстрировало преимуществ по частоте периоперационных осложнений КЭЭ (инсульт, гиперперфузионный синдром, инфаркт миокарда, хирургическая гематома) среди пациентов, нетолерантных к кросс-клампингу [21]. Н. Р. Закиржанову с соавт.…”

“…В литературе описаны различные реакции на гипоперфузию головного мозга во время пережатия сонных артерий под РА: изменение или угнетение сознания, психомоторное возбуждение, афазия, парез контралатеральных конечностей или судороги [7,18,21].…”