Importance of cerebral collateral pathways during carotid endarterectomy

Before surgery, we evaluated major intracranial collateral pathways using transcranial Doppler ultrasonography (TCD) in 50 patients who then underwent carotid endarterectomy with concurrent multimodality cerebral monitoring. Patients were grouped with respect to collateral pathways demonstrated preoperatively by TCD: Group 1, good collateralization with an anterior and/or posterior communicating artery ipsilateral to the operative carotid lesion (29 patients, 58%); Group 2, collateral pathways present but impeded by other proximal stenoses (nine patients, 18%); and Group 3, no collateralization identified (nine patients, 18%). Three patients (6%) could not be classified. TCD identified major collateral pathways with a sensitivity of 89% and a specificity of 80% when compared with arteriography. During carotid endarterectomy mean middle cerebral artery velocity, pulsatility index, and stump pressure were higher and the decrease in middle cerebral artery velocity with extracranial carotid artery cross clamping was significantly less among Group 1 patients than among Group 2 and 3 patients (p less than 0.05 for both groups). Group 1 patients required fewer intraoperative carotid artery shunts and developed fewer ischemic electroencephalographic abnormalities than did patients in Groups 2 and 3 (p less than 0.05 for both groups). TCD assessment of cerebral collateralization helps predict hemodynamic consequences of cross clamping during carotid endarterectomy.