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Propofol EEG burst suppression in carotid endarterectomy
V D'Angelo1, G Catapano, V Bozzini
1Department of Neurosurgery, Casa Sollievo della Sofferenza, Hospital, IRCCS, San Giovanni Rotondo (Foggia), Italy.
Insights
Carotid endarterectomy is a safe and effective treatment for high-grade carotid stenosis. A meticulous protocol, including patient selection and cerebral protection, minimizes operative risks and maximizes surgical benefits for both symptomatic and asymptomatic patients.
Area of Science:
- Vascular Surgery
- Neurology
- Cerebrovascular Disease
Background:
- Randomized trials confirm carotid endarterectomy as the optimal treatment for high-grade symptomatic and asymptomatic carotid stenosis.
- Minimizing perioperative risk, particularly embolic or hemodynamic cerebral ischemia, is crucial for successful carotid endarterectomy.
- Maintaining adequate intraoperative cerebral blood flow and employing meticulous surgical technique are essential.
Purpose of the Study:
- To evaluate a comprehensive protocol for carotid endarterectomy aimed at minimizing perioperative risks.
- To assess the efficacy of this protocol in patients with high-grade carotid stenosis, including both symptomatic and asymptomatic cases.
Main Methods:
- Prospective study of 100 consecutive patients undergoing carotid endarterectomy for high-grade stenosis.
- Protocol included: precise patient selection, shunt-less meticulous technique, perioperative cerebral protection (barbiturate/propofol), and comprehensive medical management.
- Preoperative assessments included CT scan, transcranial Doppler, carotid duplex scanning, angiography, and 99mTc-HMPAO SPECT.
Main Results:
- One postoperative death (myocardial infarction) and one major stroke occurred in the series of 100 patients.
- This outcome suggests a low morbidity-mortality rate associated with the implemented protocol.
Conclusions:
- The described protocol effectively minimizes the risks associated with carotid endarterectomy.
- This approach likely maximizes surgical benefits, even for patients with asymptomatic high-grade carotid stenosis.
Background:
The results of randomized trials indicate that carotid endarterectomy, performed with a low morbidity-mortality perioperative risk, is the best therapeutic option both for patients with high-grade symptomatic and asymptomatic stenosis. Since the main operative risk is represented by embolic or hemodynamic cerebral ischemia, it appears necessary to maintain an adequate intraoperative cerebral blood flow and to carry out a meticulous endarterectomy.
Methods:
On the basis of these considerations we prospectively studied a series of 100 consecutive patients operated on for high-grade carotid stenosis, by using a protocol based on: 1) an accurate selection of patients for surgery; 2) meticulous surgical technique without any shunt; 3) perioperative cerebral protection by barbiturate or propofol; 4) pre- and postoperative medical treatment of risk factors. All patients of our series performed preoperatively brain CT scan, transcranial Doppler, carotid duplex scanning, four vessel angiography, brain 99mTc-HMPAO SPECT. Eighty-two patients had symptomatic carotid stenosis ranged between 70 and 90%, 18 had carotid stenosis higher than 90%.
Results:
In this series there have been one postoperative death due to myocardial infarction and one major stroke.
Conclusions:
We think that this protocol can significantly minimize risks of endarterectomy and probably maximize the benefits of surgery, also in patients with asymptomatic high-grade carotid stenosis.