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CURRENT ISSUETHE JOURNAL OF CARDIOVASCULAR SURGERY

A Journal on Cardiac, Vascular and Thoracic Surgery


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The Journal of Cardiovascular Surgery 1999 April;40(2):249-55

VASCULAR PAPERS 

 ORIGINAL ARTICLES

Clamping ­ischemia, ­threshold ­ischemia and ­delayed inser­tion of the ­shunt ­during ­carotid endar­te­rec­tomy ­with ­patch

Deriu G. P., Milite D., Mellone G., Cognolato D., Frigatti P., Grego F.

From the Chair of Vas­cular Sur­gery Padua Med­ical ­School, ­Padua, ­Italy

Back­ground. ­Shunt inser­tion ­during ­carotid endar­te­rec­tomy (CEA) is man­da­tory to ­avoid neu­ro­log­ical ­damage due to ­clamping ­ischemia; how­ever ­shunt inser­tion ­before ­plaque ­removal has ­many incon­ven­iences (ath­e­roem­bo­lism, ­intimal dis­sec­tion, dif­fi­culty of endar­te­rec­tomy). The aim of ­this ­study is to ­verify ­whether and how ­long ­shunt inser­tion may be ­safely ­delayed to ­permit ­plaque ­removal and ­ensure cere­bral per­fu­sion ­during the ­further ­time con­suming manoeu­vres of CEA (­peeling, ­patch angio­plasty).
­Methods. ­From ­July 1990 to Feb­ruary 1996 383 ­patients under­went 411 ­CEAs ­under gen­eral anes­thesia ­with EEG con­tin­uous mon­i­toring and ­PTFE ­patch angio­plasty. A ­Pruitt-­Inahara ­shunt was rou­tinely ­inserted ­only ­after ath­e­ros­cle­rotic ­plaque ­removal. In 316 ­CEAs (76.9%) ­without EEG ­signs of cere­bral ­ischemia (­Group A) the ­mean ­clamping ­time was 10 min ±4.8 (­range 2-37 min). In 95 ­CEAs (23.1%) ­with EEG ­signs of cere­bral ­ischemia (­Group B) it was 7.3 min ±3.5 (­range 3-20 min). All ­patients had ­normal EEG sig­nals ­after ­delayed ­shunt inser­tion and reper­fu­sion (­mean 21 min, ­range 5-45 min).
­Results. In the ­short ­term ­results (­within 30 ­days) ­there was a rel­e­vant neu­ro­log­ical com­pli­ca­tion ­rate of 0.96% (2 ­major ­stroke and 2 ­lethal ­stroke); at awak­ening we ­observed 5 ­RINDs (1.21% of ­total) 1 in a ­patient ­of Group A (0.31%) and the ­other 4 in ­patients of ­Group B (4.21%).
Con­clu­sions. ­These ­data con­firm the ratio­nale of a ­delayed inser­tion of the ­shunt: actu­ally the cere­bral paren­chyma may tol­erate ­under gen­eral anes­thesia a suf­fer­ance due to ­carotid ­clamping, EEG detect­able, ­without neu­ro­log­ical def­i­cits for at ­least 7.3 min. ­This ­time is suf­fi­cient to per­form the ­most dif­fi­cult ­steps of CEA (­plaque ­removal, ­distal ­intima ­checking) ­allowing ­shunt inser­tion in a ­clean oper­atory ­field, ­without incon­ven­iences. ­Finally the ­shunt ­allows com­ple­men­tary ­time con­suming ­steps, as ­patch angio­plasty, ­with improve­ment of ­both ­short- and ­long-­term ­results.

language: English


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