Carotid endarterectomy without a shunt: The control series

Abstract

Nine hundred forty carotid endarterectomies were performed without the use of a temporary indwelling shunt. Six patients (0.6%) died, all from stroke; 17 other patients (1.8%) had another stroke, and 21 patients (2.2%) had temporary neurologic symptoms. Complete x-ray films detailing the opposite internal carotid artery and carotid artery back pressure were available for 783 operations. Correlation of stroke to back pressure, status of the contralateral internal carotid artery, preoperative neurologic deficit, and carotid clamp time was examined. Statistical analysis demonstrated significantly increased neurologic complications only if the systolic carotid back pressure was less than or equal to 50 mm Hg or the contralateral internal carotid artery was occluded. Analysis to determine if these factors were dependently related showed that when both a contralateral carotid occlusion and a carotid back pressure of less than or equal to 50 mm Hg coexisted (82 patients), the rate of permanent deficit was 11.0% compared with 2.8% when either factor was singly present and 0.9% when neither factor was present. No statistical difference exists between the group with only a single factor and those with neither factor. When a temporary shunt is not used during carotid endarterectomy, the risk of neurologic complication is increased if both a contralateral internal carotid artery occlusion and a carotid back pressure of less than or equal to 50 mm Hg coexist. The use of a shunt in this patient population may be beneficial.

Cerebral oximetry does not correlate with electroencephalography and somatosensory evoked potentials in determining the need for shunting during carotid endarterectomy

“…1,2 This continues to be the way many surgeons perform this operation. 26 Baker et al, 3 by contrast, used no shunts in a large series because of concerns about embolization or intimal injury from the shunt. Others continue to perform CEA routinely under general anesthesia without shunts.…”

“…1,2 Others proposed the use of no shunts. 3 Selective shunting came into favor, because it was recognized that only a small percentage of patients might need a shunt to prevent intraoperative ischemia and because the shunt itself might lead to an intraoperative stroke. 4,5 CEA under regional anesthesia was proposed as the simplest and the most accurate way to monitor the patient, with shunts being placed only if there was a change in neurologic status.…”

Shunting during carotid endarterectomy

“…[15][16][17][18][19][20][21] These studies are summarized in Table I. Boontje 19 reported the results of 342 CEAs without shunts with a perioperative stroke rate of 1.7% and a mortality rate of 1.5%.…”

Carotid Endarterectomy for Asymptomatic Patients:Assessing Results of a Quantitative Synthesis

“…The selection criteria for the use of a shunt include: abnormal intraoperative EEG, decreased cerebral blood flow, preoperative and/or intraoperative neurologic deficit, poor back bleeding, low internal carotid artery back pressure (stump pressure), and contralateral carotid occlusion (4). While most of these criteria were identified and included on the CE coding sheet, they were infrequently reported.…”