A Prospective Nonrandomized Study on Carotid Surgery Performed under General Anesthesia without Intraoperative Cerebral Monitoring

AbstractBackground:Cross-clamp ischemia during carotid endarterectomy can be prevented with carotid bypass shunts in vulnerable patients identified by cerebral monitoring for ischemia. We compared transcranial cerebral oximetry (TCO) with carotid stump pressure measurements for selective shunt use.Methods:We prospectively collected data on 300 consecutive patients operated on under general anesthesia between 2009 and 2016. Shunts were inserted for a 10% or greater drop in cerebral saturations and/or a mean stump pressure less than 40 mmHg.Results:Seventy-five patients, 25% of the study population, were shunted. The indication was a combined desaturation and stump pressure in 38 (50% of the shunted group), desaturation alone in 11 patients (15%), and a low stump pressure alone in 26 patients (35%). There were no significant differences in baseline characteristics between those patients who were or were not shunted, except angiographic collateral blood supply, which was more commonly identified in patients who were not shunted. A watershed infarct occurred in just one patient with borderline TCO and stump pressure measurements in whom a shunt was not used.Conclusions:There was poor concordance between TCO and stump pressures, but using both in determining the need for shunt use almost eliminated cross-clamp ischemia in this series of 300 carotid endarterectomy patients.

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Selective Shunting during Carotid Endarterectomy

Vascular ◽

10.1258/rsmvasc.13.1.23 ◽

2005 ◽

Vol 13 (1) ◽

pp. 23-27 ◽

Cited By ~ 12

Author(s):

Thelinh Q. Nguyen ◽

Linda Lind ◽

E. John Harris

Keyword(s):

General Anesthesia ◽

Carotid Endarterectomy ◽

Transient Ischemic Attack ◽

Cranial Nerve ◽

High Grade ◽

Amaurosis Fugax ◽

Shunt Group ◽

Ischemic Attack ◽

Cerebral Monitoring ◽

Selective Shunt

Carotid endarterectomy (CEA) is an effective treatment for significant carotid atherosclerosis. Perioperative stroke, a devastating complication, may be partially circumvented by shunting. However, routine shunt use is not without complications and does not benefit every patient. Our study is designed to determine whether CEA under general anesthesia, without cerebral monitoring, can be safely done with shunting only in the presence of poor internal carotid artery back-bleeding or contralateral carotid occlusion or critical stenosis. The medical records of 995 carotid operations were reviewed. A subset of 117 operations was performed on 112 patients using selective shunting. Data were analyzed and outcomes compared. For the selective shunt group, indications for redo operations ( n = 13) were recurrent asymptomatic high-grade stenosis in 69% and amaurosis fugax or transient ischemic attack in 31%. Indications for primary CEA ( n = 104) were asymptomatic high-grade stenosis in 59%, amaurosis fugax or transient ischemic attack in 36%, previous stroke in 3%, and global ischemia in 2%. A selective shunt was used in 29% of all symptomatic and 11% of all asymptomatic patients. No cerebral monitoring was used. There were no perioperative deaths and no permanent cranial nerve injuries, and there was one stroke (0.8%) from postoperative carotid thrombosis in a shunted patient. The average length of stay was 1.6 days for the non-shunt group and 2.2 days for the shunt group. The routine shunt group ( n = 878) had an overall stroke rate of 0.7%, no permanent cranial nerve deficits, and a mean hospital stay of 2.6 days. CEA under general anesthesia with selective shunting can be performed safely without cerebral monitoring.

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General Anesthesia Versus Local Anesthesia for Carotid Surgery

Neurosurgery ◽

10.1227/01.neu.0000351422.52956.17 ◽

2009 ◽

Vol 64 (5) ◽

pp. N10-N11 ◽

Cited By ~ 1

Author(s):

RICARDO J. KOMOTAR ◽

OMAR N. SYED ◽

E. SANDER CONNOLLY

Keyword(s):

General Anesthesia ◽

Local Anesthesia ◽

Carotid Surgery

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Reallocation of Carotid Surgery Activity with the Support of Telemedicine in a COVID-Free Clinic during COVID-19 Pandemic

European Neurology ◽

10.1159/000517381 ◽

2021 ◽

pp. 1-5

Author(s):

Nicola Troisi ◽

Massimo Cincotta ◽

Consuelo Cardinali ◽

Donato Battista ◽

Aldo Alberti ◽

...

Keyword(s):

Carotid Stenosis ◽

National Health System ◽

Early Postoperative Period ◽

Staff Nurses ◽

Carotid Surgery ◽

Free Clinic ◽

Symptomatic Carotid ◽

Systemic Complication ◽

Symptomatic Carotid Stenosis ◽

Cerebral Monitoring

The aim of this study is to report the reallocation of carotid surgery activity with the support of telemedicine in a COVID-free clinic during COVID-19 pandemic. Patients with symptomatic carotid stenosis or asymptomatic vulnerable plaques were reallocated to a COVID-free private clinic which began to cooperate with the National Health System during the emergency. Quick training of staff nurses was performed. Surgeons moved to the COVID-19 free clinic. Remote cerebral monitoring was performed with the support of telemedicine. Twenty-four patients underwent standard carotid endarterectomy with eversion technique. Five patients (20.8%) had recently symptomatic stenosis, and the remaining 19 patients (79.2%) had a risky asymptomatic carotid stenosis. No technical issue with remote cerebral monitoring was detected. In the early postoperative period, no neurological/systemic complication was observed. Three patients under dual antiplatelet therapy (12.5%) had neck hematoma. All patients were discharged the day after surgery. In our preliminary experience, reallocation in a COVID-free clinic allowed us to maintain a functioning carotid surgery activity during COVID-19 pandemic. A multidisciplinary approach and support of telemedicine were crucial. Training of unskilled nurse staff was necessary.

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