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

Copyright © 2000 EDIZIONI MINERVA MEDICA

lingua: Inglese

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


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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.

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