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The selection for shunting in patients with severe bilateral carotid lesions
E Sbarigia1, F Speziale, M Colonna
1Department of Vascular Surgery, University of Rome, La Spienza, Italy.
Insights
Carotid endarterectomy for severe bilateral carotid lesions is safe with intraoperative cerebral monitoring. This technique significantly reduces stroke risk in high-risk patients undergoing carotid surgery.
Area of Science:
- Vascular Surgery
- Neurology
- Anesthesiology
Background:
- Patients with severe bilateral carotid artery lesions face high stroke risk.
- Carotid endarterectomy is a proposed treatment, but perioperative complications, often linked to clamping intolerance, remain a concern.
Purpose of the Study:
- To evaluate the safety and efficacy of carotid endarterectomy with intraoperative cerebral monitoring in patients with severe bilateral carotid lesions.
- To determine if advanced monitoring can reduce perioperative stroke risk in this high-risk population.
Main Methods:
- Retrospective review of 74 patients with severe bilateral carotid lesions (stenosis and contralateral occlusion) undergoing carotid endarterectomy over 7 years.
- Comparison of outcomes between patients managed under general anesthesia with electroencephalogram (EEG) monitoring and stump pressure, versus local-regional anesthesia with selective shunting based on neurological monitoring.
Main Results:
- Overall neurological morbidity was 1.3% and mortality was 1.3%.
- Patients under local-regional anesthesia with selective shunting experienced no postoperative neurological complications.
- Patients under general anesthesia with EEG monitoring had a 5.4% stroke rate, with one fatality.
Conclusions:
- Carotid endarterectomy can be performed safely in patients with severe bilateral carotid lesions using accurate intraoperative cerebral monitoring.
- Local-regional anesthesia with selective shunting appears to offer superior neurological outcomes compared to general anesthesia with EEG monitoring in this patient group.
Abstract:
Patients with severe bilateral carotid lesions (stenosis and contralateral internal carotid occlusion) are at high risk of having a stroke, and carotid endarterectomy has been proposed as the best treatment. In spite of improvements in surgical technique, this operation is still associated with significant perioperative complications (5-13%) which are frequently (up to 40%) correlated with intolerance to internal carotid artery clamping. For this reason, intraoperative cerebral monitoring able to accurately detect ischaemia during surgery would be useful. Reviewing our experience from the last 7 years in 74 patients operated on for stenosis and contralateral occlusion of the internal carotid artery, we found a 1.3% neurological morbidity and 1.3% mortality rate. Presenting symptoms included focal transient ischaemia attacks (TIAs) in 57 patients, stroke in 16 patients and two patients were asymptomatic. Half of these patients (37) were operated on under general anaesthesia with electroencephalogram (EEG) monitoring, stump pressure measurement and selective shunting. In this group, two patients (5.4%) sustained a postoperative stroke, one of which was fatal. The remaining 37 patients were operated on under local-regional anaesthesia with selective shunting on the basis of neurological deficit onset or loss of consciousness during the test clamp. There were no postoperative neurological complications in this group but one patient died of acute myocardial infarction on the 6th postoperative day. This experience suggests that it is possible to perform carotid endarterectomy in patients with severe bilateral lesions with a postoperative complication rate similar to that in patients with less complicated obstructive lesions if accurate intraoperative cerebral monitoring is used.