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Online ISSN 1827-1847
Chiarandini S. 1, Adovasio R. 1, Monti F. 2, Pancrazio F. 2, Ziani B. 2, Zamolo F. 2
1 Vascular Surgery Unit Vascular Surgery Specialization School University of Trieste, Trieste, Italy
2 Clinical Neurophisiology Unit Trieste University-Hospital, Trieste, Italy
Aim. Staging of bilateral carotid endarterectomy (CEA) may represent a prevention of postoperative morbidity related to neurological events and reperfusion syndrome. Carotid artery cross clamping ischemia and shunting is one of the cause of intraoperative neurological morbidity in carotid surgery. Some authors recently suggested that short interval between the procedures in staged bilateral CEA, may increase carotid artery cross clamping ischemia and the risk of cerebral reperfusion syndrome. The purpose of this study is to report carotid artery cross clamping ischemia in groups of patients with different anatomical and clinical conditions and compare the need of shunting between bilateral staged CEA and unilateral endarterectomy, and between the first and the second procedure in staged bilateral CEA.
Methods. A retrospective review was carried out on 315 patients: 287 of them underwent unilateral CEA, while 28 underwent bilateral staged CEA. Demographic features, clinical data and technical details are referred. Operative mortality and morbidity are compared between the two groups. Carotid artery cross clamping ischemia has been defined as any change in EEG monitoring or any clinical neurological deficit reversed by the shunt insertion. Carotid artery cross clamping ischemia has been compared in subgroups of patiens undergoing ipsilateral CEA having contralateral carotid artery occlusion, or contralateral carotid artery stenosis and, for each subgroup, has been related to clinical features. The need of shunting is compared between bilateral staged CEA and unilateral CEA and between the first and second surgical procedure in bilateral staged CEA.
Results. Seven patients asymptomatic for contralateral carotid side became symptomatic for transient ischemic attack or stroke after ipsilateral procedure while waiting for the second one. Bilateral staged CEA had no mortality/morbidity while unilateral CEA group had a mortality/morbidity rate of 1.39%. Carotid artery cross clamping ischemia predictive factors are: presence of contralateral internal carotid artery occlusion (P<0.05) and the presence of previous ischemic cerebral lesions in patients with bilateral carotid stenosis (P<0.01). Staged bilateral CEA does not seem to have an incresed incidence of carotid artery cross clamping ischemia compared to unilateral CEA in patients with bilateral carotid involvment. Data showed an higher incidence of clamping ischemia during the first procedure than during the second one, but incidence of cerebral ischaemic events or clinical signs reperfusion syndrome was not higher.
Conclusion. Bilateral staged CEA does not seem to have a higher risk of cross clamping ischemia if compared to unilateral carotid CEA: in relation to the interval between the procedures waiting at least one month may reduce the risk of cross clamping ischemia and reperfusion syndrome, but a longer interval may carry a higher risk of embolic events related to the evolution of contralateral plaque.