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[Cerebral protection from ischaemia during carotid endarterectomy]
A N Vachev1, M G Prozhoga1, O V Dmitriev1
1Department of Faculty Surgery, Samara State Medical University of the RF Ministry of Public Health, Samara, Russia.
Insights
Controlled hypertension effectively protects the brain during carotid endarterectomy, even with varying internal carotid artery pressure. Individualized hemodynamic management eliminated the need for shunts, ensuring patient safety.
Area of Science:
- Vascular Surgery
- Neurology
- Anesthesiology
Background:
- Carotid endarterectomy (CEA) is a procedure to remove plaque from carotid arteries, reducing stroke risk.
- Cerebral protection is crucial during CEA, especially when internal carotid artery (ICA) pressure is low.
- Traditional methods like intraluminal shunts carry risks and may not always be necessary.
Purpose of the Study:
- To evaluate the efficacy of controlled systemic hypertension for cerebral protection during CEA.
- To assess this strategy across different levels of retrograde pressure in the ICA.
- To determine if individualized hemodynamic management can obviate the need for shunts.
Main Methods:
- 150 patients undergoing CEA were enrolled.
- General anesthesia with mechanical ventilation and invasive hemodynamic monitoring was employed.
- Cerebral perfusion was assessed via ICA retrograde pressure, categorizing patients into three groups based on the retrograde pressure index (RPI <30, 30-39, ≥40).
- Controlled systemic hypertension was induced using phenylephrine and norepinephrine during ICA cross-clamping.
Main Results:
- No statistically significant differences were observed in central hemodynamics, operation duration, or ICA cross-clamp time among the RPI groups.
- A statistically significant difference was found in the required systolic arterial pressure levels for effective cerebral protection (p<0.05).
- Importantly, there were no instances of cerebral circulation impairment, myocardial infarction, or death in any group.
Conclusions:
- Individualized correction of central hemodynamics provides adequate collateral compensation for cerebral blood flow during CEA.
- Controlled systemic hypertension is an effective method for cerebral protection in CEA.
- This approach allows for the safe omission of intraluminal shunts in selected patients.
Abstract:
The purpose of this study was to assess efficacy of cerebral protection during carotid endarterectomy by means of controlled systemic hypertension in patients presenting with various levels of retrograde pressure in the internal carotid artery. The study enrolled a total of 150 patients subjected to carotid endarterectomy. The operation was carried out under general anaesthesia with artificial pulmonary ventilation and was accompanied by haemodynamic monitoring with invasive control of arterial pressure, as well as primary and additional correction of central haemodynamics. Cerebral perfusion was assessed by measuring retrograde pressure in the internal carotid artery. The retrograde pressure index was calculated, according to which the patients were subdivided into three groups: those with values less than 30, with values from 30 to 39, and with values of 40 and more. Controlled systemic arterial hypertension was used as cerebral protection during the period of cross-clamping of the internal carotid artery, with phenylephrine and norepinephrine administered for this purpose. The parameters of central haemodynamics, time intervals of the operation, and the duration of internal carotid artery cross-clamping in the groups did not statistically differ (p>0.05). A statistically significant difference was revealed in the level of systolic arterial pressure necessary for cerebral protection (p<0.05). There were no cerebral circulation impairments, myocardial infarctions, nor lethal outcomes. A conclusion was drawn that individualized correction of central haemodynamics ensured a sufficient level of collateral compensation of the cerebral blood flow, thus making it possible to refuse from using intraluminal shunts.
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