Longer time interval between carotid cross-clamping and shunting is associated with increased 30-day stroke and death
P P Wisman1, R P Tutein Nolthenius, S C Tromp
1Department of Vascular Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands. p.p.wisman@umcutrecht.nl
Insights
Minimizing shunt-to-shunt time (NST) during carotid endarterectomy (CEA) is crucial. Longer NST significantly increases the risk of stroke or death within 30 days after CEA surgery.
Area of Science:
- Vascular Surgery
- Neurology
- Clinical Outcomes Research
Background:
- Carotid endarterectomy (CEA) is a proven procedure for significant carotid stenosis.
- The impact of shunt-to-shunt time (NST) on post-CEA outcomes remains unclear.
Purpose of the Study:
- To investigate the relationship between NST and 30-day morbidity and mortality after CEA.
- To determine if NST duration influences patient outcomes following carotid endarterectomy.
Main Methods:
- Retrospective analysis of 851 CEAs using a selective shunting protocol.
- Included 156 patients who required intraoperative shunting based on transcranial Doppler and EEG monitoring.
Main Results:
- A longer NST was significantly associated with an increased 30-day stroke/death rate (P=.004, OR=1.5/min).
- No significant influence on stroke/death rate was observed for age, gender, stenosis type, patch use, or microembolic signals.
Conclusions:
- Prolonged NST during CEA with selective shunting increases the risk of 30-day stroke or death.
- Rapid shunt placement is strongly recommended to improve patient safety and outcomes after CEA.
Background:
The benefit of carotid endarterectomy (CEA) in patients with a significant (>70%) (a)symptomatic stenosis has been proven thoroughly in major trials. It is unknown whether, after cross-clamping the carotid artery, the time interval between determination that a shunt is needed and the actual functioning of the shunt, defined as the need for shunt-to-shunt time (NST), influences 30-day morbidity and mortality rate after CEA.
Methods:
Experienced vascular surgeons performed 851 CEAs with a selective shunting protocol based on perioperative transcranial Doppler measurement and electroencephalographic findings, and data were analyzed retrospectively. The study included 156 shunted patients.
Results:
Longer NST was associated with an increase in the 30-day stroke/death rate. A binary logistic regression model was used to determine a 2-tailed P value of .004 and an odds ratio of 1.5/min increase of the NST. There was no influence on stroke-death rate of gender, age, symptomatic or asymptomatic stenosis, the use of a patch or not, or the number of periprocedural microembolic signals.
Conclusion:
If CEA is performed with a selective shunting protocol, a longer NST increases the 30-day stroke/death rate. These results support a strong recommendation that shunt placement should be as quick as possible.
