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[Carotid surgery and its monitoring in our experience]
C Bertoglio1, M Prandi, T Carissimi
1Cattedra di Semeiotica Chirurgica R, Università degli Studi di Genova.
Insights
Carotid endarterectomy (CEA) is a safe stroke prevention surgery, though it carries risks. Improved monitoring, like transcranial Doppler (TCD), can enhance safety and expand surgical indications.
Area of Science:
- Vascular Surgery
- Neurology
- Cerebrovascular Disease
Background:
- Carotid endarterectomy (CEA) is a key procedure for preventing stroke caused by carotid bifurcation stenosis.
- A significant number of patients undergoing CEA are symptomatic, highlighting the need for effective stroke prevention strategies.
Purpose of the Study:
- To evaluate the safety and efficacy of carotid endarterectomy (CEA) in preventing stroke.
- To analyze the outcomes of CEA in a large cohort of patients over a 17-year period.
- To assess the role of intraoperative monitoring and identify areas for risk reduction.
Main Methods:
- A retrospective analysis of 215 carotid endarterectomy (CEA) procedures performed on 168 patients over 17 years.
- Preoperative assessment included echo-Duplex scanning, arteriography, CT, or MRI.
- Intraoperative monitoring utilized stump pressure and transcranial Doppler (TCD) of the middle cerebral artery (MCA) to guide selective shunt use (12% of cases).
Main Results:
- The global major stroke/mortality rate was 3.3%, with a mortality rate of 0.5%.
- Symptomatic patients had a major stroke/mortality rate of 4.2%, while asymptomatic patients had a rate of 0%.
- The 4-year postoperative stroke incidence was 8.5%, with an annual mortality rate of 1.6%.
Conclusions:
- Carotid endarterectomy (CEA) is a safe and effective procedure for preventing cerebral infarctions.
- Enhanced intraoperative monitoring, particularly transcranial Doppler (TCD), is crucial for understanding and preventing clamp-induced ischemia.
- Improved monitoring techniques can potentially decrease operative risks and broaden surgical indications for asymptomatic patients.
Abstract:
Carotid endarterectomy (CEA) is the elective surgical procedure to prevent stroke due to stenosis of the carotid bifurcation. During a period of 17 years the Authors performed 215 operations on the carotid arteries of 168 patients. The average age was 64.6 and the male/female ratio was 3/1. Patients were symptomatic in 75.8% of cases and asymptomatic in the remaining 24.2%. Preoperative investigations consisted of echo-Duplex scanning, arteriography, cerebral CT or MRI. Indications for surgery were: stenosis wider than 70% in 173 cases, ulcerated or "high-risk" stenosis in symptomatic patients in 37 cases, and carotid malformation in 5 cases. The intraoperative use of shunt (12% of the operations) was selective, depending from the results of our monitoring system: stump pressure and transcranial Doppler (TCD) of the middle cerebral artery (MCA) ipsilateral to the procedure. The global major stroke/mortality rate was 3.3% (7/215), the minor morbidity was 8.8% (19/215). Mortality rate was 0.5% (1/215). The major stroke/mortality rate for symptomatic patients was 4.2% and for asymptomatic patients was 0%. The average follow up was 58 months (range 1-192) for 200/215 patients, with 15/215 patients (7%) lost. The postoperative incidence of stroke after 4 years was 8.5% (17/200), with an annual mortality rate of 1.6% (min. after 2 months, max. 118, average 55 months). CEA is a safe procedure to prevent cerebral infarctions, but it still carries an operative risk. A better monitoring would allow to understand the mechanisms of clamp-induced ischaemia and prevent it, therefore decreasing the operative risks and extending the surgical indications to a higher ratio of asymptomatic subjects. TCD is becoming essential for our goal: it is useful in deciding to insert an intraoperative shunt, check the carotid flow, recognize embolic events, and also during the initial phase of carotid preparation.