Seventeen‐year experience with routine shunting in carotid artery surgery

Abstract

Safety of carotid artery surgery depends on proper case selection, meticulous surgical technique, and appropriate protection of the brain during carotid artery cross‐clamping. Various methods have been devised to determine the adequacy of collateral circulation, none of which has been proven practical and totally reliable. Attempts at increasing cerebral perfusion to the ischemic portion of the brain by induced hypertension, hypercarbia, and hypocarbia have been ineffective. The purpose of this presentation is to report our experience with routine intraluminal shunting in carotid artery surgery during the past 17 years. Advantages of routine shunting include maintenance of regional cerebral blood flow at the preclamping level and the elimination of any need for monitoring and haste during surgery. Insertion of the tube, properly done, does not injure the arterial wall and should not cause embolization. The presence of the tube within the arterial lumen does not interfere with exposure of the atheroma, yet it facilitates repair of the incision and prevents stricture by faulty suturing technique. Results of carotid artery surgery measured by the incidence of stroke are compared between shunted and nonshunted series. A review of the literature confirms our impression that shunting reverses ischemic changes detected by EEG and regional cerebral blood flow determinations. The usefulness of shunting in the surgical management of internal carotid aneurysm, kinked carotid artery, carotid body tumor, and carotid‐subclavian bypass graft is also described.

Routine or Selective Carotid Artery Shunting for Carotid Endarterectomy (and Different Methods of Monitoring in Selective Shunting)

“…Although some surgeons advocate routine shunting, others prefer to use shunts selectively or avoid them altogether. 3,4 Potential disadvantages of shunting include complications such as air and plaque embolism and carotid artery dissection, and an increased risk of local complications such as nerve injury, hematoma, infection, and long-term restenosis. 5 However, reliable data on these risks are limited.…”

The ischemic tolerance of neural tissue and the need for monitoring and selective shunting during carotid endarterectomy.

“…The primary cause for neurological complications at this institution following surgery are complications related to hyperperfusion rather than hypoperfusion. STROKE VOL 14, No 1, JANUARY-FEBRUARY 1983 shunting"- 31,32 or some form of monitoring with selective shunting,…”

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

“…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.…”

“…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.…”

“…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.…”