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A Journal on Vascular and Endovascular Surgery

Official Journal of the Italian Society of Vascular and Endovascular Surgery
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Giornale Italiano di Chirurgia Vascolare 1998 December;5(4):201-13

language: English, Italian

Transcranial Doppler and loco­re­gion­al anaesthe­sia in carot­id sur­gery. A com­par­i­son of sev­er­al meth­ods to ­detect clamp­ing ischae­mia

Varroni A., Gizzi E., Totaro R. *, Mangiacotti B., Carlucci M. D., Ventura M., Spartera C.

From the Department and School of Specialisation in Vascular Surgery (Head: Prof. C. Spartera) * Neurological Clinic Department of Internal Medicine and Public Health
University of L’Aquila, Italy


Background. Several tech­niques ­have ­been pro­posed for intra­op­er­a­tive cere­bral mon­i­tor­ing in carot­id endar­te­rec­to­my to iden­ti­fy the ­patients who do not tol­er­ate carot­id clamp­ing and ­require cere­bral pro­tec­tion. The aim of ­this ­study is to eval­u­ate intra­cra­ni­al col­lat­er­al cir­cu­la­tion, cor­re­late the neu­ro­log­i­cal stat­us (­gold stan­dard) ­with ­stump pres­sure meas­ure­ment, EEG mon­i­tor­ing and TCD val­ues, and deter­mine the crit­i­cal lev­els of ­cross-clamp­ing tol­er­ance for select­ing ­those ­patients who ­need a ­shunt.
Methods. In the ­last two ­years we per­formed 109 carot­id endar­te­rec­to­mies ­under loco­re­gion­al anaesthe­sia (84 ­males, 25 ­females; ­mean age: 66.4±9.4). Transcranial Doppler (TCP) mon­i­tor­ing was ­used com­bined ­with elec­tro­en­ceph­a­log­ra­phy (EEG), LRA and ­stump pres­sure meas­ure­ment for the pre­ven­tion of cere­bral ischae­mia.
Results. The per­cent­age of resid­u­al ­mean mid­dle cere­bral ­artery veloc­ity (mMCAv) dur­ing carot­id ­artery com­pres­sion was sig­nif­i­cant­ly cor­re­lat­ed ­with mMCAv at carot­id clamp­ing. Cross-clamp­ing TCD val­ues ­were sig­nif­i­cant­ly low­er in ­patients ­with intra­op­er­a­tive neu­ro­log­i­cal def­i­cits (37.2±16 vs 13.27±8 cm/sec; p<0.0001). Cross-clamp­ing val­ues ­were ­also low­er in ­patients ­with EEG abnor­mal­ities (36.39±16 vs 20.23±14 cm/sec; p<0.001). Five min­utes ­after clamp­ing ­time mMCAv ­increased sig­nif­i­cant­ly (36.3±14.6 cm/sec vs 34.7±14.7 cm/sec; p<0.001). According to neu­ro­log­i­cal stat­us, a ­shunt was insert­ed in 12 cas­es. TCD ­showed a reduc­tion of 70% in mMCAv at ­cross- clamp­ing in 10 cas­es. In ­this ­series the sen­si­tiv­ity and spec­i­fic­ity of EEG mon­i­tor­ing was 75% and 96.8%, respec­tive­ly. TCD mon­i­tor­ing ­shows a sen­si­tiv­ity and spec­i­fic­ity of 83.3% and 96.9% respec­tive­ly, ­while ­stump pres­sure ­showed a sen­si­tiv­ity of 81.8% and a spec­i­fic­ity of 87.4%.
Conclusions. EEG and TCD mon­i­tor­ing are com­ple­men­tary tech­niques. Patients ­with mMCAv reduc­tions of ≥70% at ­cross- clamp­ing ­require a ­shunt. In our opin­ion, the ver­sa­til­ity of TCD sug­gests a ­more exten­sive appli­ca­tion in the ­field of carot­id sur­gery.

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