Benefit of selective shunt use during carotid endarterectomy under regional anesthesia

Vascular ◽  
2020 ◽  
Vol 28 (5) ◽  
pp. 505-512
Author(s):  
João M Rocha-Neves ◽  
Juliana Pereira-Macedo ◽  
Marina F Dias-Neto ◽  
José Paulo Andrade ◽  
Armando A Mansilha
Keyword(s):  
Postoperative Complications ◽  
Carotid Artery ◽  
Carotid Endarterectomy ◽  
Regional Anesthesia ◽  
Univariate Analysis ◽  
Cerebral Hypoperfusion ◽  
Neurological Deficits ◽  
Tertiary Referral Hospital ◽  
Stroke Risk Factor ◽  
Shunt Group

Objectives Carotid cross-clamping during endarterectomy exposes the patient to intraoperative neurological deficits due to embolism or cerebral hypoperfusion. To prevent further cerebrovascular incidents, resorting to shunt is frequently recommended. However, since this method is also considered a stroke risk factor, the use is still controversial. This study aims to shed some light on the best approach regarding the use of shunt in symptomatic cerebral malperfusion after carotid artery cross-clamping. Methods From January 2012 to January 2018, 79 patients from a tertiary referral hospital who underwent carotid endarterectomy with regional anesthesia for carotid artery stenosis and manifested post-clamping neurologic deficits were prospectively gathered. Shunt use was left to the decision of the surgeon and performed in 31.6% (25) of the patients. Demographics, comorbidities, imaging tests, and clinical/intraoperative features were evaluated. For data assessment, univariate analysis was performed. Results Regarding 30-day stroke, 30-day postoperative complications (stroke, surgical hematoma, hyperperfusion syndrome), and cranial nerve injury, no significant differences were found ( P = 0.301, P = 0.460, and P = 0.301, respectively) between resource to shunt and non-shunt. Clamping and surgery times were significantly higher in the shunt group ( P < 0.001 and P = 0.0001, respectively). Conclusions Selective-shunting did not demonstrate superiority for patients who developed focal deficits regarding stroke or other postoperative complications. However, due to the limitations of this study, the benefit of shunting cannot be excluded. Further randomized trials are recommended for precise results on this matter with current sparse clinical evidence.

Hyperperfusion Syndrome: Toward a Stricter Definition

Neurosurgery ◽  
2003 ◽  
Vol 53 (5) ◽  
pp. 1053-1060 ◽  
Author(s):  
◽  
Shelagh B. Coutts ◽  
Michael D. Hill ◽  
William Y. Hu ◽  
Garnette R. Sutherland
Keyword(s):  
Carotid Artery ◽  
Intracerebral Hemorrhage ◽  
Carotid Endarterectomy ◽  
Clinical Presentation ◽  
Imaging Techniques ◽  
Neurological Deficits ◽  
Acute Hemorrhage ◽  
Motor Weakness ◽  
Hyperperfusion Syndrome ◽  
Angioplasty And Stenting

Abstract OBJECTIVE Hyperperfusion syndrome is a rare and potentially devastating complication of carotid endarterectomy or carotid artery angioplasty and stenting. With the advent of new imaging techniques, we reviewed our experience with this phenomenon. METHODS This report is a retrospective review of 129 consecutive cases of carotid endarterectomy performed between June 1, 2000, and May 31, 2002, and 44 consecutive cases of carotid artery angioplasty and stenting performed between January 1, 1997, and May 31, 2002. We specifically searched for examples of patients who developed postprocedural nonthrombotic neurological deficits that typified the hyperperfusion syndrome. RESULTS Seven cases of hyperperfusion syndrome occurred, four after endarterectomy (3.1% of carotid endarterectomy cases) and three after stenting (6.8% of stenting cases). The cases of hyperperfusion were classified as presenting with 1) acute focal edema (two cases with stroke-like presentation, attributable to edema immediately after revascularization), 2) acute hemorrhage (two cases of intracerebral hemorrhage immediately after stenting and one case immediately after endarterectomy), or 3) delayed classic presentation (two cases with seizures, focal motor weakness, and/or late intracerebral hemorrhage at least 24 hours after endarterectomy). CONCLUSION Hyperperfusion syndrome may be more common and more variable in clinical presentation than previously appreciated.

scholarly journals Factors affecting survival in 43 consecutive patients after surgery for spinal metastases from thyroid carcinoma

2015 ◽  
Vol 23 (4) ◽  
pp. 419-428 ◽  
Author(s):  
Jonathan N. Sellin ◽  
Dima Suki ◽  
Viraat Harsh ◽  
Benjamin D. Elder ◽  
Daniel K. Fahim ◽  
...  
Keyword(s):  
Overall Survival ◽  
Multivariate Analysis ◽  
Thyroid Cancer ◽  
Postoperative Complications ◽  
Systemic Disease ◽  
Univariate Analysis ◽  
Spinal Metastases ◽  
Neurological Deficits ◽  
Cancer Center ◽  
Preoperative Embolization

OBJECT Spinal metastases account for the majority of bone metastases from thyroid cancer. The objective of the current study was to analyze a series of consecutive patients undergoing spinal surgery for thyroid cancer metastases in order to identify factors that influence overall survival. METHODS The authors retrospectively reviewed the records of all patients who underwent surgery for spinal metastases from thyroid cancer between 1993 and 2010 at the University of Texas MD Anderson Cancer Center. RESULTS Forty-three patients met the study criteria. Median overall survival was 15.4 months (95% CI 2.8–27.9 months) based on the Kaplan-Meier method. The median follow-up duration for the 4 patients who were alive at the end of the study was 39.4 months (range 1.7–62.6 months). On the multivariate Cox analysis, progressive systemic disease at spine surgery and postoperative complications were associated with worse overall survival (HR 8.98 [95% CI 3.46–23.30], p < 0.001; and HR 2.86 [95% CI 1.30–6.31], p = 0.009, respectively). Additionally, preoperative neurological deficit was significantly associated with worse overall survival on the multivariate analysis (HR 3.01 [95% CI 1.34–6.79], p = 0.008). Conversely, preoperative embolization was significantly associated with improved overall survival on the multivariate analysis (HR 0.43 [95% CI 0.20–0.94], p = 0.04). Preoperative embolization and longer posterior construct length were significantly associated with fewer and greater complications, respectively, on the univariate analysis (OR 0.24 [95% CI 0.06–0.93] p = 0.04; and OR 1.24 [95% CI 1.02–1.52], p = 0.03), but not the multivariate analysis. CONCLUSIONS Progressive systemic disease, postoperative complications, and preoperative neurological deficits were significantly associated with worse overall survival, while preoperative spinal embolization was associated with improved overall survival. These factors should be taken into consideration when considering such patients for surgery. Preoperative embolization and posterior construct length significantly influenced the incidence of postoperative complications only on the univariate analysis.

scholarly journals Outcome of Carotid Endarterectomy in a Tertiary Center of Nepal: A Retrospective Study

2021 ◽  
Vol 43 (1) ◽  
pp. 31-35
Author(s):  
Prashiddha B Kadel ◽  
Uttam K Shrestha ◽  
Kajan R Shrestha ◽  
Dinesh Gurung
Keyword(s):  
Postoperative Complications ◽  
Carotid Artery ◽  
Carotid Endarterectomy ◽  
Carotid Artery Disease ◽  
Total Study Population ◽  
Tertiary Center ◽  
Artery Disease ◽  
Postoperative Cardiac Event ◽  
Clinical Records

Introduction Carotid endarterectomy for carotid artery disease is one of the surgeries performed by vascular surgeons for carotid artery disease. The objective of this study is to describe the early and late outcome of the patient undergoing carotid endarterectomy and the association between the complication and comorbidities present previously in the patient. MethodsAll patients undergoing carotid endarterectomy at Manmohan Cardiothoracic Vascular and Transplant Centre between April 2010 to April 2020 were included. The follow-up data for upto a year from medical and clinical records, telephone interview regarding the immediate and late postoperative complications in patients with and without comorbidities were investigated and compared. ResultsThe total study population was 42 patients. Two patients (4.7%) developed stroke, one immediately in postoperative period and the other during follow up. There were two deaths (4.7%) postoperatively due to cardiac events and three (7.14%) recurrences of carotid stenosis among whom one (2.5%) developed late stroke. Twenty six patients (61.90%) were symptomatic prior to the procedure of which 20 patients (47.61%) had brain infarct. Overall one year survival was 95.2% post procedure and overall complication rate was 7.14%. The consequence in the form of death and stroke occurred more in the patients with comorbidities (3vs1) p=0.42. ConclusionThe immediate and late postoperative complications following carotid endarterectomy were death (4.7%), stroke (4.7%), cranial nerve injury (9.5%). The most frequent cause of death was postoperative cardiac event. Though major complications occurred more frequently in patients having comorbidities, it was statistically insignificant.

Carotid Endarterectomy with External Shunt: A New Device and Indication for Use: Technical Note

Neurosurgery ◽  
2001 ◽  
Vol 48 (5) ◽  
pp. 1174-1177 ◽  
Author(s):  
Masaaki Uno ◽  
Kyoko Nishi ◽  
Kiyohito Shinno ◽  
Shinji Nagahiro
Keyword(s):  
Carotid Artery ◽  
Carotid Endarterectomy ◽  
Common Carotid Artery ◽  
External Carotid Artery ◽  
Technical Note ◽  
Neurological Deficits ◽  
External Carotid ◽  
Shunt System ◽  
New Device ◽  
The Common

Abstract OBJECTIVE We designed a new external shunt system and evaluated its indications and efficacy in patients undergoing carotid endarterectomy (CEA). METHODS In 8 of 332 CEA procedures, external shunts were placed between the common carotid artery and the internal carotid artery (ICA). This procedure was implemented for one of two indications: 1) a change in electroencephalographic and/or somatosensory evoked potential readings immediately after ICA occlusion, or 2) elongation of the ICA made safe insertion of an internal shunt impossible. In addition, a shunt was placed between the common carotid artery and the external carotid artery to establish collateral circulation from the external carotid artery to the intracranial circulation, which is essential during ICA occlusion. RESULTS All external shunts were functional, and electroencephalography and somatosensory evoked potentials demonstrated no significant abnormalities during the CEAs. All patients awoke from surgery without manifestation of new neurological deficits. CONCLUSION Our new external shunt device proved safe and efficacious in cases that did not permit the placement of an internal shunt.

Hemodynamic Compromise During Carotid Angioplasty and Stenting

2011 ◽  
Author(s):  
A. G. Lynch ◽  
M. T. Walsh
Keyword(s):  
Carotid Artery ◽  
Carotid Endarterectomy ◽  
Carotid Artery Disease ◽  
Arterial Disease ◽  
Neurological Deficits ◽  
Carotid Angioplasty ◽  
Hemodynamic Compromise ◽  
Artery Disease ◽  
Angioplasty And Stenting ◽  
Carotid Angioplasty And Stenting

Modern surgical treatment of arterial disease is moving towards minimally invasive procedures, as the benefits are numerous. However, one area that is resisting this trend is the treatment of carotid artery disease. For the past number of decades carotid endarterectomy surgery has been referred to as the “gold standard” in the treatment of carotid artery disease. However, in recent year’s carotid angioplasty and stenting (CAS) has emerged to challenge carotid endarterectomy surgery (CES) as a viable alternative for the prevention of strokes. However uptake of this procedure has been hindered due to the peri-operative complications associated with the treatment. During this procedure blood flow in one of the internal carotid arteries supplying blood to the brain is interrupted for a period of time. However, it has been shown that not all patients can accommodate this interruption. Qureshi et al. suggests that ischemic neurological deficits occur in 3 to 13% of patients as a result of hemodynamic compromise.

Reversal of a Dense, Persistent, Holohemispheric Neurological Deficit after an Endarterectomy of the Carotid Artery: Case Report

Neurosurgery ◽  
1991 ◽  
Vol 29 (2) ◽  
pp. 261-264 ◽  
Author(s):  
Rickey L. McKenzie ◽  
Issam A. Awad ◽  
Cathy A. Sila
Keyword(s):  
Carotid Artery ◽  
Carotid Endarterectomy ◽  
Neurological Deficit ◽  
Acute Stage ◽  
Neurological Dysfunction ◽  
Neurological Deficits ◽  
Ct Scans ◽  
Neurological Improvement ◽  
Computed Tomographic ◽  
The Right

Abstract The role and timing of a carotid endarterectomy in the setting of an acute ischemic stroke-in-evolution remain controversial. Although computed tomographic (CT) scans typically show no abnormalities in the acute stage, it is generally agreed that a dense neurological deficit (hemiplegia) and/or multiple modality neurological disturbance (involving motor, sensory, gaze, and visual field impairment) represent contraindications to surgical intervention. We present a case of an acute right holohemispheric neurological deficit including dense hemiplegia, hemisensory loss, gaze disturbance, hemineglect, and impaired level of consciousness. This persisted for 4 days while serial CT scans showed no evidence of infarction. Angiography revealed pre-occlusive stenosis of the right internal carotid artery with sluggish antegrade flow. The anterior collaterals of the circle of Willis were impaired, and the right middle cerebral artery territory filled via the posterior communicating artery. Despite the dense neurological deficit persisting for 4 days, a carotid endarterectomy was performed. Gradual neurological improvement was noted within hours of the operation, and all neurological deficits resolved within the subsequent 3 days. This case is consistent with prolonged holohemispheric hemodynamic compromise below the threshold of neurological dysfunction, but above the threshold of tissue infarction (“idling neurons”). Features assisting in the recognition of this unusual scenario and the indications and risks of revascularization in this setting are discussed.

scholarly journals Advantages of regional anesthesia for carotid endarterectomy

2016 ◽  
Vol 10 (1) ◽  
pp. 55-59
Author(s):  
Vadim V. Shmelyov ◽  
M. I Neimark
Keyword(s):  
Postoperative Complications ◽  
Carotid Endarterectomy ◽  
Regional Anesthesia ◽  
Cerebral Circulation ◽  
Total Intravenous Anaesthesia ◽  
Cerebral Damage ◽  
Cervical Plexus ◽  
Intravenous Anaesthesia ◽  
Mental Functions

At 190 patients with carotid endarterectomy the relative assessment of total intravenous anaesthesia with use propofol, penetrating blockage of a cervical plexus and inhalation sevofluran is made. Cerebral circulation parametres, markers of cerebral damage, a state of the highest mental functions were investigated. It is shown that for each kind of anaesthesia specific changes of parametres of the cerebral blood-groove, defining level neuronal damages that affects on a state of number and character of postoperative complications are characteristic.

scholarly journals Efficacy of near-infrared spectroscopy cerebral oximetry on detection of critical cerebral perfusion during carotid endarterectomy under regional anesthesia

VASA ◽  
2020 ◽  
Vol 49 (5) ◽  
pp. 367-374
Author(s):  
João P. Rocha-Neves ◽  
Juliana Pereira-Macedo ◽  
André L. Moreira ◽  
José P. Oliveira-Pinto ◽  
Graça Afonso ◽  
...  
Keyword(s):  
Infrared Spectroscopy ◽  
Oxygen Saturation ◽  
Carotid Endarterectomy ◽  
Regional Anesthesia ◽  
Near Infrared Spectroscopy ◽  
Operating Characteristic ◽  
Near Infrared ◽  
Cerebral Oximetry ◽  
Cerebral Hypoperfusion ◽  
Cerebral Oxygen

Summary: Background: Patients undergoing carotid endarterectomy (CEA) may suffer from cerebral hypoperfusion during the carotid cross-clamping. Near-infrared spectroscopy cerebral oximetry (NIRS) is a non-invasive method of regional cerebral oxygen saturation measurement reflecting changes in cerebral blood flow during CEA. The main goal of the study was to evaluate the accuracy of the NIRS in detecting cerebral hypoperfusion during CEA under regional anesthesia (RA) and compare it with awake neurological testing. Patients and methods: A prospective observational study of 28 patients that underwent CEA in RA and manifested neurologic deficits, and 28 consecutive controls from a tertiary and referral center, was performed. All patients were monitored with NIRS cerebral oximetry and awake testing as the control technique. Subsequently, operating characteristic curve and Cohen’s kappa coefficient were determined to evaluate the reliability of the monitoring test. Results: NIRS presented a sensitivity of 27.3% and a specificity of 89.3% in comparison to awake testing. Receiver operating characteristic (ROC) curve analysis demonstrated that a decrease of at least 20% in cerebral oxygen saturation is the best threshold to infer cerebral hypoperfusion. However, the respective area under the curve (AUROC) was 0.606 (95% CI: 0.456–0.756, P = 0.178) with a calculated Cohen’s kappa of 0.179, P = 0.093. Regarding 30-days outcomes, only awake testing has shown significant associations with stroke and postoperative complications ( P = 0.043 and P = 0.05), which were higher in patients with post-clamping neurologic deficits. Conclusions: NIRS demonstrated a reduced discriminative capacity for critical cerebral hypoperfusion, and does not seem to add substantial clinical benefits to the awake test.

Carotid Cross-Clamp intolerance during carotid endarterectomy in regional anesthesia

2021 ◽  
Vol 29 (1) ◽  
pp. 66-72
Author(s):  
Payman Majd ◽  
Peter Galkin ◽  
Mahmoud Tayeh ◽  
Thomas Herzmann ◽  
Michael Gores ◽  
...  
Keyword(s):  
Blood Flow ◽  
Carotid Artery ◽  
Carotid Endarterectomy ◽  
Regional Anesthesia ◽  
Surgical Procedure ◽  
Systolic Arterial Pressure ◽  
Tolerance Test ◽  
External Carotid ◽  
Cerebrovascular Events ◽  
History Of

During surgical endarterectomy, carotid cross clamping is needed for arteriotomy and plaque removal. Carotid cross clamping reduces the blood flow to the circle of Willis, and some patients show intolerance to the temporary occlusion of the internal carotid artery (ICA). Aim. This study demonstrates locoregional anesthesias safety in patients with carotid cross clamping intolerance (CCI) and the risk factors that predict this condition. Materials and Methods. All patients who underwent surgical carotid endarterectomy between January 2019 and December 2020 (n=53, 29 were male, age (median with range) 78 (56-90) years) were identified in a retrospective review. The indication for surgical treatment was made for a stenosed ICA of 70-99% or in the case of symptomatic stenosis. Surgical technique. An incision is made at the front edge of the sternocleidomastoid muscle. The common carotid artery (CCA) is identified and isolated from the surrounding tissues with sharp dissection and continued toward the bifurcation. Next, the internal and external carotid arteries can be isolated. Heparin (5000 U) is administrated intravenously, and the systolic arterial pressure is increased and kept over 160 mm Hg. In the next step, the cross clamping tolerance test is performed for 60 s. During clamping, the patient is neurologically meticulously observed. In the case of CCI, the operation proceeds with the insertion of a temporary shunt. The arteriotomy is started in the CCA and continues to the ICA. The plaque is completely removed, and the arteriotomy incision is covered with a patch. Before completing the suture, the clamps are partially removed to flush out the debris using the blood flow. Now, the external and common artery can be released. Finally, the clamp of the ICA can be removed. Results. Eight patients had cross clamping tolerance test intolerance. In all these cases, the surgical procedure was continued with a shunt. The further operation course remained uncomplicated. The in-hospital mortality was nil, and a transient ischemic attack occurred in only one case. Coronary artery disease (CAD) [odds ratio (OR) 12.65, 95% confidence interval (CI) 1.43-112.50], a history of cerebrovascular events [OR 10.50, 95% CI 1.83-60.30], and contralateral stenosis of 70% or more [OR 26.66, 95% CI 2.29-304.37] presented a significant association with the CCI and the need to shunt. The remaining factors showed no significant association with intolerance. Conclusions. Regional anesthesia is a safe method for identifying patients with CCI and safely performing the surgical procedure. Contralateral stenosis of the ICA and a history of cerebrovascular events are significant factors to predict CCI.

scholarly journals Can ankle-brachial index be used as a predictor for carotid artery shunt application during carotid endarterectomy?

2021 ◽  
Vol 30 (2) ◽  
pp. 102-106
Author(s):  
Mehmet Akif Önalan ◽  
Didem Melis Öztaş ◽  
Ayşenur Önalan ◽  
Metin Onur Beyaz ◽  
Siraslan Bahseliyev ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Peripheral Arterial Disease ◽  
Carotid Endarterectomy ◽  
Regional Anesthesia ◽  
Medical Records ◽  
Odds Ratio ◽  
Ankle Brachial Index ◽  
Arterial Disease ◽  
The Mean ◽  
Peripheral Arterial

Objectives: This study aims to investigate the possible relationship between low ankle-brachial index (ABI) and shunt requirement during carotid endarterectomy (CEA) operations. Patients and methods: Medical records of a total of 56 patients (40 males, 16 females; mean age: 65.6±8.4 years; range, 48 to 82 years) who underwent CEA between January 2013 and December 2016 were retrospectively reviewed. The ABI was measured in all patients at the time of hospital admission. Peripheral arterial disease was defined as having an ABI of ≤0.90 in either leg. Selective carotid artery shunt strategy was applied to all patients who underwent CEA under regional anesthesia. Results: Forty-eight (85.8%) patients were symptomatic. Peripheral arterial disease was diagnosed in 25 (44.6%) patients with ABI measurements. Eleven (19.6%) patients required shunt placement due to neurological deterioration during the carotid clamping test. The mean ABI of 11 (19.6%) patients was 0.8±0.15, while the ABI was less than 0.90 in 10 (17.8%) patients. There was a statistically significant correlation between perioperative shunt usage and peripheral arterial disease (odds ratio [OR]: 19.68, 95% confidence interval [CI]: 2.3-164.4; p=0.001). Conclusion: Low ABI appears to be related to a higher rate of shunt requirement in patients undergoing CEA under regional anesthesia with a selective shunt strategy in our modest cohort.

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