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ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY
A Journal on Vascular and Endovascular Surgery
Giornale Italiano di Chirurgia Vascolare 2001 September;8(3):217-29
language: English, Italian
Routinely delayed shunt insertion during carotid endarterectomy
Grego F., Lepidi S., Damiani N., Zaramella M., Antonello M., Bonvini S., Deriu G. P.
From the Azienda Ospedaliera, Padua Department of Vascular Surgery University of Padua, Padua, Italy (Chief: Prof. G. P. Deriu)
Background. The aim of this study is to verify whether and how long shunt insertion during carotid endarterectomy (CEA) can be safely delayed to permit plaque removal and ensure cerebral perfusion during the further time-consuming maneuvers of CEA (peeling, patch angioplasty).
Methods. From July 1990 to December 1999, 1067 patients underwent 1176 CEAs under general anesthesia with continuous EEG monitoring and PTFE patch angioplasty. A Pruitt-Inahara shunt was routinely inserted only after atherosclerotic plaque removal.
Results. In 927 CEAs (79%) with EEG signs of cerebral ischemia (Group A) first clamping time was 7.5±2.12 min (range: 2-37 min). In 249 CEAs (21%) with EEG signs of cerebral ischemia (Group B) clamping time was 5.12±1.44 min (range: 3-20 min). All patients had normal EEG signals after delayed shunt insertion and reperfusion. Short-term results (within 30 days) showed a neurological relevant complicate rate of 1.1%, with 11 major strokes and two lethal strokes. At awakening, 23 RINDs (1.9% of total) were observed, with nine recorded in Group A (0.9%) and 14 in Group B (5.6%).
Conclusions. Under general anesthesia and EEG monitoring, cerebral parenchyma can tolerate ischemia secondary to carotid clamping for at least 3.12±1.44 min without producing neurological deficits. This interval is long enough to perform the most difficult steps of CEA and allows shunt insertion in a clean operative field. The shunt also permits complementary time-consuming steps such as patch angioplasty, thus improving both short and long-term results.