Current practice--routine use of shunting in carotid endarterectomy. Cost reduction and surgical training

Sophisticated methods of determining cerebral blood flow have reduced the use of shunting in carotid endarterectomy in 6-25% of cases. However teaching university hospitals still have to provide their young vascular surgeons with experience in the shunting procedure. Since complications of shunting have been related to the surgeon's experience in the technique, our study aimed to evaluate a policy of the routine use of shunting in carotid endarterectomy by vascular surgeons in training. In addition to concluding how this policy would affect the optimum outcome of our patients. The probable reduction of hospital charges was also evaluated.

A prospective audit of the results of 423 consecutive carotid endarterectomies performed by a senior vascular surgeon (the first 97 cases) and a vascular surgeon in training under the supervision of a senior vascular surgeon (326 cases), with routine use of an indwelling intraluminal shunt, in a university hospital in Athens.

During the study period, 337 patients admitted to our department were managed surgically independently of any demanding surgery due to the anatomy and the extension of internal carotid artery disease. The perioperative stroke/death rate at 30 days was 0.47%, but the stroke rate alone was 0%. Minor complications amounted to 5.4%, with an increased but not significant difference in patients presenting contralateral internal carotid occlusion. There was no difference in complication rates when a young surgeon performed the shunting procedure compared with the experienced senior surgeon's results, but this was achieved after training in the method in the first 97 cases. The reduction of the total cost was related to avoidance of cost of the devices necessary for determination of the cerebral circulation during carotid clamping and the cost of specially trained personnel. Our policy resulted in only eight patients having to be treated in the intensive care unit for a total of 13 days.

Experience in a large number of shunting procedures are required for a young vascular surgeon's training, in order to achieve optimum results. This can be done in teaching hospitals by using the method more frequently than required. Moreover in the contest of continuing changes in the practice of carotid endarterectomy and the economic restrictions on health expenditure, the routine use of shunting resulted in cost saving without jeopardizing the patients' outcome.