The prognostic value of cerebral oxygenation and retrograde pressure during carotid endarterectomy

Abstract

<p><strong>Aim:</strong> The study aimed to determine the predictive value of retrograde pressure (RP) indicators and cerebral oxygenation in the evaluation of ischemic brain damage during carotid endarterectomy (CEA).<br /><strong>Methods:</strong> This nonrandomized, prospective pilot study included 87 patients with asymptomatic stenosis greater than 70% who underwent carotid endarterectomy under general anesthesia. Brain tolerance to ischemia was determined by measuring and evaluating RP (∆rSO2) and cerebral oxygenation (rSO2) during a trial clamping of the carotid artery. Depending on the degree of reduction of cerebral oxygenation from the baseline (∆rSO2) during a trial clamping of the carotid artery, patients were divided into 3 groups: the first group (n = 35) - ∆rSO2 <9.9%, the second group (n = 35) - ∆rSO2 from 10 to 19.9%, the third group (n = 14) - ∆rSO2 ≥ 20%. The primary end-point of the study was to obtain the AUC value exceeding 0.70, which could mean a high predictive quality of research methods. <br /><strong>Results:</strong> There were no perioperative strokes or myocardial infarctions during the study. Average time of carotid artery clamping was 28 (26-30) minutes. 3 patients who received temporary shunts were excluded from the study because of a simultaneous decrease in the rSO2 and ∆rSO2 indicators. It was found out that S-100 and NSE protein concentration in all groups did not significantly differ at different stages (p> 0.05). A temporary shutdown of blood flow in the carotid artery during CEA is accompanied by significant elevation of cerebral damage markers (S100, NSE) concentration with their subsequent restoration at 3 days after surgery. ROC - analysis revealed that none of the methods for assessing cerebral ischemic tolerance (RP, ∆rSO2 and rSO2) is precise enough (AUC > 0.7) to predict brain injury during carotid endarterectomy. Satisfactory, but a poor quality (AUC< 0.7) of predicting an increase in the reference values of S-100 protein neuromarkers was demonstrated by retrograde pressure, while the other indicators (∆rSO2 and rSO2) did not exceed the area under the curve (AUC) over 0.60. <br /><strong>Conclusion:</strong> Methods of measuring retrograde pressure and cerebral oxygenation are merely a reflection of the collateral blood flow and the cerebral oxygenation level due to their close relationship, but they cannot be used as predictors of ischemic neuronal damage during carotid endarterectomy because of poor predictive quality.</p>

The factors of unfavorable prognosis of various surgical strategies in patients with combined coronary and brachiocephalic lesion in remote postoperative period

“…Контроль и модифи-кация данных факторов приобретает особое значение при симультанной хирургической операции, когда имеет место суммация агрессивных хирургических факторов. По данным литературы [36], концентрация в крови ней-роспецифических белков S-100 и NSE повышается в за-висимости от длительности пережатия ВСА во время операции на БЦА. И хотя более широкое применение нашли методы измерения оксигенации ГМ, по мнению ряда авторов [36], они не способны точно прогнозиро-вать ишемическое повреждение нейронов.…”

“…По данным литературы [36], концентрация в крови ней-роспецифических белков S-100 и NSE повышается в за-висимости от длительности пережатия ВСА во время операции на БЦА. И хотя более широкое применение нашли методы измерения оксигенации ГМ, по мнению ряда авторов [36], они не способны точно прогнозиро-вать ишемическое повреждение нейронов. В результате чего факт более длительного пережатия ВСА во время КЭЭ приобретает особое значение.…”

“…Control and modification of these factors are particularly important in case of simultaneous surgery when there is a summation of aggressive surgical factors. According to literature data, blood concentration of neurospecifical proteins S-100 and NSE is increased depending on ICA cross-clamping time [36]. Some authors consider that cerebral oxygenation measurement can not predict accurately ischemic neuronal injury despite its wide application.…”

“…Some authors consider that cerebral oxygenation measurement can not predict accurately ischemic neuronal injury despite its wide application. In view of this prolonged ICA cross-clamping is very important during CEE [36]. Perhaps, the use of intraoperative temporary shunt may have a protective role to prevent adverse events.…”

The combined use of proximal and distal protection devices uring carotid stenting: A case report

“…Лечение стенотических поражений каротидных артерий включает медикаментозную терапию и реваскуляризацию методами каротидной эндартерэктомии (КЭА) или каротидного стентирования (КС). Несмотря на то что результаты рандомизированных исследований сравнения КЭА и КС показали низкую частоту перипроцедурального инсульта при «открытых» вмешательствах [5], КС считается более предпочтительным у пациентов высокого хирургического риска [6][7][8].…”