Completion Arteriogram After Carotid Endarterectomy Yields Lower Perioperative Stroke Rate

Introduction: Completion imaging following carotid endarterectomy (CEA) remains controversial. We present our experience performing routine completion arteriography (CA). Methods: A retrospective review of our prospectively maintained institutional database was performed for patients undergoing isolated CEA. Results: 1439 isolated CEAs with CA were performed on 1297 patients. CEA was for asymptomatic lesions in 70% (1003) of cases. There were no complications related to arteriography. An abnormal arteriogram documented significant abnormalities in the internal carotid artery (ICA) and prompted revision in 1.7% (24/1439) of cases: 20 unsatisfactory distal endpoints of the endarterectomy (12 residual stenoses, 7 intimal flaps, and 1 dissection), 3 kinks or stenoses within the body of the patch, and 1 thrombus. Of the 20 distal endpoint lesions, stent deployment was used in 17 cases and patch revision in 3 cases. The other 4 cases were treated by patch angioplasty (3) or thrombectomy (1). None suffered a perioperative stroke. The overall 30-day stroke, death, and combined stroke/death rate for the 1439 patients in our series was 1.5% (22), .5% (7), and 1.9% (27), respectively. The combined stroke/death rate for asymptomatic lesions was 1.1% (11/1003) and for symptomatic lesions was 2.5% (11/436). Of the 22 strokes in the entire series (all with normal CA), 15 were non-hemorrhagic strokes ipsilateral to the CEA; 14 were confirmed to have widely patent endarterectomy sites by CT-A (13) or re-exploration and repeat arteriography (1). The occluded site was re-explored and underwent thrombectomy, but no technical problems were identified. The remaining strokes were hemorrhagic (4 reperfusion syndrome and 1 surgical site bleeding) or contralateral to the CEA (2). Conclusion: Although not all patients in this series who underwent intraoperative revision due to abnormal CA might have suffered a stroke, performing this simple and safe study may have halved our overall perioperative stroke rate from 3.2% to 1.5%.

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Stroke From Carotid Endarterectomy: When and How to Reduce Perioperative Stroke Rate?

European Journal of Vascular and Endovascular Surgery ◽

10.1053/ejvs.2001.1360 ◽

2001 ◽

Vol 21 (6) ◽

pp. 484-489 ◽

Cited By ~ 56

Author(s):

G.J de Borst ◽

F.L Moll ◽

H.D.W.M van de Pavoordt ◽

H.W Mauser ◽

J.C Kelder ◽

...

Keyword(s):

Carotid Endarterectomy ◽

Stroke Rate ◽

Perioperative Stroke

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Hyperglycemia Independently Increases the Risk of Perioperative Stroke, Myocardial Infarction, and Death after Carotid Endarterectomy

Yearbook of Anesthesiology and Pain Management ◽

10.1016/s1073-5437(08)70106-2 ◽

2007 ◽

Vol 2007 ◽

pp. 112-113

Author(s):

S. Black

Keyword(s):

Myocardial Infarction ◽

Carotid Endarterectomy ◽

Perioperative Stroke

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Contralateral Internal Carotid Artery Occlusion Impairs Early But Not 30-Day Stroke Rate Following Carotid Endarterectomy

Angiology ◽

10.1177/0003319710369792 ◽

2010 ◽

Vol 61 (7) ◽

pp. 705-710 ◽

Cited By ~ 5

Author(s):

Erik Bagaev ◽

A. Maximilian Pichlmaier ◽

Theodosios Bisdas ◽

Mathias H. Wilhelmi ◽

Axel Haverich ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Carotid Endarterectomy ◽

Internal Carotid ◽

Artery Occlusion ◽

Carotid Artery Occlusion ◽

Internal Carotid Artery Occlusion ◽

Stroke Rate ◽

Contralateral Internal Carotid Artery

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Carotid-subclavian arterial reconstruction: Concomitant ipsilateral carotid endarterectomy increases risk of perioperative stroke

Surgery ◽

10.1016/j.surg.2007.03.014 ◽

2007 ◽

Vol 142 (3) ◽

pp. 393-397 ◽

Cited By ~ 13

Author(s):

Gina M. Risty ◽

Thomas H. Cogbill ◽

Clark A. Davis ◽

Pamela J. Lambert

Keyword(s):

Carotid Endarterectomy ◽

Arterial Reconstruction ◽

Perioperative Stroke

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IP087. Unplanned Shunting During Carotid Endarterectomy in Recently Symptomatic Patients is Associated With a Higher Risk of Perioperative Stroke

Journal of Vascular Surgery ◽

10.1016/j.jvs.2019.04.167 ◽

2019 ◽

Vol 69 (6) ◽

pp. e134

Author(s):

Scott R. Levin ◽

Alik Farber ◽

Philip P. Goodney ◽

Nkiruka Arinze ◽

Thomas W. Cheng ◽

...

Keyword(s):

Carotid Endarterectomy ◽

Perioperative Stroke

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P.118 An experience with combined cerebral oximetry and stump pressure measurement to guide shunt insertion during carotid endarterectomy

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2016.217 ◽

2016 ◽

Vol 43 (S2) ◽

pp. S47-S47

Author(s):

R Kesarwani ◽

M Findlay

Keyword(s):

Blood Flow ◽

Carotid Endarterectomy ◽

Pressure Measurement ◽

Intraoperative Monitoring ◽

Cerebral Oximetry ◽

Cerebral Oxygen ◽

Collateral Blood Flow ◽

Shunt Insertion ◽

Perioperative Stroke ◽

Stump Pressure

Background: Cross-clamp ischemia during carotid endarterectomy (CEA) can cause perioperative stroke. Selectively shunting patients based on intraoperative monitoring modalities that assess risk for ischemia can reduce the occurrence of immediate stroke. An experience with combined cerebral oximetry and stump pressure measurement to direct selective shunting is presented here. Methods: Study comparing intraoperative monitoring data, the decision to shunt, and presence of immediate post-operative deficits. Patients were shunted if either cerebral oxygen saturation dropped by more than 10% by cerebral oximetry, or stump pressure during cross-clamping was less than 40 mmHg. Cross-clamp ischemia was determined by the presence of ipsilateral neurological deficit upon awakening. Results: 245 patients were included in this study. 22% were shunted. Patients who were not shunted were significantly more likely to have collateral blood flow detected on angiography. Immediate post-operative stroke was not encountered in any of the patients included in the study. One patient who met shunting criteria but was excluded since he could not have a shunt inserted due to difficult anatomy did suffer stroke. Conclusions: With the dual-monitoring criteria presented here, 22% of patients were shunted. With the exception of one patient who could not have a shunt placed, no immediate post-operative stroke was encountered.

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