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PubMed1987

Carotid endarterectomy. Who needs it?

Although carotid endarterectomy is one of the most frequently performed operations in this country, recent evidence casts doubt on its advisability, particularly for patients with ocular manifestations of cerebral ischemia. The following evidence is that: the risk of future stroke in untreated patients with amaurosis fugax, retinal plaques, and infarcts is less than 3% per year, far lower than that expected for cerebral (hemispheric) transient ischemic attacks (TIAs); the perioperative risk of stroke and death after endarterectomy may be much higher than previously suspected; and aspirin is a comparatively risk-free and moderately effective alternative to endarterectomy. Because of the questions raised about the risk-to-benefit ratio of endarterectomy, patients with ocular manifestations of cerebral ischemia should be considered for this operation only as part of a proposed randomized collaborative study.

Carotid Arteries↗
PubMed2003

Postoperative infection associated with polyester patch angioplasty after carotid endarterectomy.

OBJECTIVES: Postoperative infection is one of the most dreaded complications associated with use of synthetic patches for carotid endarterectomy. Although polyester patches were used extensively for carotid patch angioplasty throughout the last decade, few reports detail cases of deep patch infection. We describe our experience with polyester patch infections after carotid endarterectomy. Patients and methods From January 1996 through December 2001 we treated polyester patch infections after carotid endarterectomy in 10 patients. RESULTS: The interval from primary carotid endarterectomy to presentation with infection ranged from 11 days to 30 months. All patients underwent repeat operation that involved tissue debridement, excision of the polyester patch, and either interposition grafting or patch angioplasty with autologous vein. No perioperative stroke or death occurred; however, 1 patient had transient hoarseness, and in 1 patient a pseudoaneurysm developed that required additional surgical repair with a saphenous vein interposition graft. All patients remain well and free of infection with follow-up as long as 56 months. CONCLUSIONS: Infection is a serious and rare complication of carotid patch angioplasty with polyester material. Nonetheless, it can be treated successfully with good results and acceptable morbidity with soft tissue debridement, prosthetic patch excision, and either patch angioplasty or interposition grafting with autologous vein.

Aged↗
PubMed1994

Carotid endarterectomy in awake patients: its safety, acceptability, and outcome.

PURPOSE: The purpose of this study was to determine the safety and efficacy of performing carotid endarterectomy procedures with the patient receiving cervical block anesthetic. METHODS: Over the last 14 years, 654 carotid endarterectomy procedures were performed with patients receiving regional anesthetic. Intraluminal shunts were placed on demand, if neurologic changes with clamping of the carotid artery developed in the patient. During the same period, 419 cases were done with the patients receiving general anesthetic. Choice of anesthetic was based on surgeon and patient preference. RESULTS: In the regional anesthetic group the indications for operation included transient ischemic attack (311), asymptomatic hemodynamically significant stenosis (146), amaurosis fugax (106), stroke (86), restenosis (3), and aneurysm (2). Shunts were used in 46 of 654 cases (7%). Conversion from regional to general anesthetic was required in seven patients (1.1%). The operative mortality rate was 0.76% (5 of 654). Permanent nonfatal neurologic deficits occurred in 0.76% (5 of 654), and temporary neurologic deficits occurred in 1.07% (7 of 654). CONCLUSIONS: On the basis of these results, we believe regional cervical block anesthetic is an acceptable option to the routine use of shunts performed with the patient receiving general anesthetic during carotid endarterectomy. In addition, the ability to continuously assess the awake patient receiving cervical block may contribute to a decrease in perioperative stroke and mortality rates while simplifying functional cerebral monitoring during carotid endarterectomy.

Adult↗
PubMed1995

Stroke rate is markedly reduced after carotid endarterectomy by avoidance of protamine.

PURPOSE: Postoperative neurologic injury remains a significant risk of carotid endarterectomy. Mechanisms include embolization of debris and formation of thrombus on the newly endarterectomized surface. We hypothesized that the risk of postoperative neurologic injury would be lower in those patients who did not receive protamine for reversal of heparin anticoagulation. METHODS: We reviewed 348 consecutive primary carotid endarterectomies performed since January 1, 1986, to determine the relationship between surgical outcomes and reversal of heparin anticoagulation. Patients undergoing additional simultaneous cardiovascular procedures were excluded. One hundred ninety-three patients received protamine after completion of the endarterectomy. The remaining 155 patients did not receive any protamine. RESULTS: All patients in both groups survived to discharge. There were no strokes in those patients who did not receive any protamine; however, the stroke rate in the protamine group was 2.6% (5 of 193), p < 0.045. The incidence of hematoma requiring reexploration was 1.0% (2 of 193) and 1.9% (3 of 155) in the protamine and no-protamine groups, respectively (p = NS). Intraoperative shunting was used more frequently in the no-protamine group (84% vs 67%, p < 0.001), and patch angioplasty was performed more frequently in the protamine group (35% vs 15%, p < 0.001). However, neither shunting nor patching significantly influenced stroke rates. CONCLUSIONS: We conclude that carotid endarterectomy without reversal of heparin anticoagulation is associated with a reduced postoperative stroke rate without a significant increase in morbidity rates.

Aged↗
PubMed1996

Adapting practice patterns to a managed care environment: carotid endarterectomy--a case example.

The way American medicine is practiced is changing rapidly. By the beginning of the next century, most Americans may be enrolled in for-profit managed care plans in which physicians are responsible for both a budget and a population of patients. As health care is revolutionized, the overriding issue is whether the mission of health care organizations will be simply to contain costs, or whether it will be to increase the value (i.e., the quality) that we get for the money we are willing to spend on health care. The purpose of this article is to illustrate for carotid endarterectomy how quality can remain on the health care reform agenda. Vascular surgeons must assume a leadership role, and they must be willing to alter their practice patterns. More specifically, they should: (1) support and facilitate the development of clinically-detailed multispecialty criteria that describe under what circumstances carotid endarterectomy is both appropriate and necessary; (2) support the development of a system for publicly reporting outcome data by physician and hospital; (3) support regionalization of carotid endarterectomy; (4) conduct a prospective assessment of appropriateness before the procedure is performed; (5) consider changing the system by which carotid angiographies are read to increase their reliability; and (6) help develop a system to ensure that people who need carotid endarterectomy are offered the procedure.

Cost Control↗
PubMed1997

Duplex imaging findings predict stenosis after carotid endarterectomy.

PURPOSE: This study was performed to determine whether early duplex findings predicted restenosis after carotid endarterectomy. METHODS: One hundred ninety-two symptomatic patients who underwent carotid endarterectomy were studied with color duplex imaging at 1 day and 1 week after surgery to identify minor residual disease (causing < 50% stenosis), arterial kinking, and suture stricture, and to measure the external and luminal diameters of the carotid bulb and distal internal carotid artery. Patients were then observed prospectively with duplex surveillance for a median of 24 months to identify > 50% restenosis. RESULTS: Twenty-five stenoses > 50% of the operated carotid artery (13%) were identified, four at 1 day (residual) and 21 at a median follow-up of 6 months (restenosis). On multiple logistic regression analysis, > 50% restenosis was found to be associated with minor day-1 residual stenosis (p = 0.01) and with small luminal diameter of the distal internal carotid artery (p = 0.03) as measured 1 week after carotid endarterectomy. Life table analysis showed restenosis at 24 months to be more common for patients with below-median than patients with above-median carotid bulb external diameter (18% vs 5%, respectively; p = 0.01). CONCLUSIONS: Duplex scanning within a week of carotid endarterectomy identifies > 50% residual stenosis, in addition to minor residual 25% to 50% stenosis and small carotid dimensions, which are good predictors of > 50% restenosis at 6 months.

Adult↗
PubMed1997

Duplex morphologic features of the reconstructed carotid artery: changes occurring more than five years after endarterectomy.

PURPOSE: To determine the late morphologic appearance of the carotid artery after endarterectomy and to relate the morphologic characteristics to the development of recurrent carotid stenosis and subsequent neurologic symptoms. METHODS: Eighty-eight carotid reconstructions (51% included patch angioplasty) in 82 patients were studied 5 or more years after carotid endarterectomy. Duplex color flow imaging was used to determine morphologic characteristics of the carotid endarterectomy site and to document the occurrence, time interval, and progression of recurrent internal carotid artery stenosis. The spatial orientation of recurrent wall thickening, presence of calcium, arterial wall texture, and presence of laminar flow were evaluated. Recurrent stenoses were categorized using standard duplex criteria. RESULTS: The mean duration of follow-up was 99 months (range, 60 to 138 months). Arterial wall calcium was identified in 23% (n = 18), a smooth luminal surface in 57% (n = 46), and laminar flow in 52% (n = 42). Recurrent wall thickening developed in 58 vessels (66%), involving the posterior segment of the vessel in 95%, and anterior, lateral, or medial aspects in 24% (n = 14). Restenosis > 50% diameter reduction occurred in 4% of common carotid arteries (n = 3) and in 15% of internal carotid arteries (n = 13). Ten of the internal carotid artery restenoses occurred after a mean of 76 months (range, 13 to 132 months), and the three remaining patients had asymptomatic occlusions after a mean of 61 months (range, 1 to 96 months). Neurologic events referable to the reconstructed carotid artery occurred in three patients at a mean of 77 months; two were a result of recurrent carotid disease. One symptomatic patient and two asymptomatic patients (3.7%) underwent a second ipsilateral reconstruction for recurrent high-grade stenosis. CONCLUSIONS: The carotid artery remains smooth, with laminar flow and without calcification, in the majority of reconstructions that were observed over a long term. There is a low incidence of subsequent ipsilateral neurologic events or significant recurrent stenosis, both of which usually occur late in the postoperative period. This study documents the long-term durability of carotid endarterectomy in providing risk reduction for stroke.

Aged↗
PubMed1997

Clinical experience with everted cervical vein as patch material after carotid endarterectomy.

PURPOSE: The aim of this study was to evaluate the clinical efficacy of everted cervical veins used as patches after carotid endarterectomy. METHODS: A prospective nonrandomized comparative analysis was performed on patients with either everted cervical veins or saphenous veins as patches after carotid endarterectomy. Two hundred ninety-six patients underwent 329 carotid endarterectomies during an 8 1/2-year period (1987 to 1995). Saphenous vein patches were used in 125 (38%) cases and everted cervical veins in 167 (51%). These two groups were compared clinically and by sonographic surveillance. The mean follow-up of patients in this study was 27 +/- 11 months. RESULTS: No significant differences were noted regarding postoperative morbid events between the everted cervical and saphenous vein patch groups. Even at 5 years the percentage of patients without stroke for both groups exceeded 95%. Duplex surveillance studies also showed comparable percentages of recurrent moderate (50% to 69%) and severe (70% to 99%) stenosis, 5.6% and 6.9%, respectively, for everted cervical vein and 5.4% and 6.5%, respectively, for saphenous vein. Cumulative recurrent stenosis-free rates at 5 and 6 years exceeded 82% for each of the patch study groups. CONCLUSIONS: Based on the results of this study everted cervical veins are useful adjuncts to carotid endarterectomy, when patch angioplasty is necessary or desirable. Their performance is comparable to that of saphenous veins. Cervical veins are usually available, even when the saphenous vein is absent or inadequate. In addition, good saphenous veins can be spared and lower extremity excisions avoided.

Aged↗
PubMed1997

Cost-effectiveness of carotid endarterectomy in asymptomatic patients.

PURPOSE: The purpose of this study was to determine the cost-effectiveness of carotid endarterectomy for treating asymptomatic patients with > or = 60% internal carotid stenosis, based on outcomes reported in the Asymptomatic Carotid Atherosclerosis Study (ACAS). METHODS: A cost-effectiveness analysis was performed using a Markov decision model in which the probabilities for base-case analysis (average age, 67 years; 66% male; perioperative stroke plus death rate, 2.3%; ipsilateral stroke rate during medical management, 2.3% per year) were based on ACAS. The model assumed that patients who had TIAs or minor strokes during medical management crossed over to surgical treatment, and used the NASCET data to model the outcome of these now-symptomatic patients. Average cost of surgery ($8500), major stroke ($34,000 plus $18,000 per year), and other costs were based on local cost determinations plus a review of the published literature. Cost-effectiveness was calculated as the incremental cost of surgery per quality-adjusted life year (QALY) saved when compared with medical treatment, discounting at 5% per year. Sensitivity analysis was performed to determine the impact of key variables on cost-effectiveness. RESULTS: In the base-case analysis, surgical treatment improved quality-adjusted life expectancy from 7.87 to 8.12 QALYs, at an incremental lifetime cost of $2041. This yielded an incremental cost-effectiveness ratio of $8,000 per QALY saved by surgical compared with medical treatment. The high cost of care after major stroke during medical management largely offset the initial cost of endarterectomy in the surgical group. Furthermore, 26% of medically managed patients eventually underwent endarterectomy because of symptom development, which also decreased the cost differential. Sensitivity analysis demonstrated that the relative cost of surgical treatment increased substantially with increasing age, increasing perioperative stroke rate, and decreasing stroke rate during medical management. CONCLUSION: For the typical asymptomatic patient in ACAS with > or = 60% carotid stenosis, our results indicate that carotid endarterectomy is cost-effective when compared with other commonly accepted health care practices. Surgery does not appear cost-effective in very elderly patients, in settings where the operative stroke risk is high, or in patients with very low stroke risk without surgery.

Aged↗
PubMed1998

Accuracy of duplex ultrasound in evaluating carotid artery anatomy before endarterectomy.

PURPOSE: Anatomic features, such as a high carotid bifurcation (< 1.5 cm from the angle of the mandible), excessive distal extent of plaque (> 2.0 cm above the carotid bifurcation), or a small diameter (< or = 0.5 cm) redundant or kinked internal carotid artery can complicate carotid endarterectomy. In the past, arteriography was the only preoperative study capable of imaging these features. This study assessed the ability of duplex ultrasound to evaluate their presence before surgery. METHODS: A consecutive series of 20 patients who underwent 21 carotid endarterectomies had preoperative duplex ultrasound evaluations of these anatomic features. These evaluations were correlated with operative measurements from an observer blinded to the duplex findings. RESULTS: The mean difference between duplex and operative measurements for the distance between the carotid bifurcation and the angle of the mandible, the distal extent of plaque, and the internal carotid artery diameter was 0.9 cm, 0.3 cm, and 0.8 mm, respectively. The correlation coefficient between the two methods was 0.86, 0.75, and 0.59, respectively. Duplex ultrasound predicted a high carotid bifurcation, excessive distal extent of plaque, or a redundant or kinked internal carotid artery with 100% sensitivity (p < 0.05, p < 0.01, and p < 0.001, respectively). The sensitivity of duplex ultrasound in predicting a small internal carotid artery diameter was 80%. The specificity of duplex ultrasound for predicting excessive distal extent of plaque, small internal carotid artery diameter, high carotid bifurcation, and a coiled or kinked carotid artery was 92%, 56%, 100%, and 100%, respectively. CONCLUSION: Duplex ultrasound can predict the presence of anatomic features that may complicate carotid endarterectomy. Preoperative duplex imaging of these features may be helpful in patients who undergo carotid endarterectomy without preoperative arteriography.

Aged↗
PubMed1999

Intracerebral hemorrhage after carotid endarterectomy: incidence, contribution to neurologic morbidity, and predictive factors.

PURPOSE: With a diminishing rate of cardiac and neurologic events after carotid endarterectomy, intracerebral hemorrhage is gaining increasing importance as a cause of perioperative morbidity and mortality. To date, information has been largely anecdotal, and there has been no comparison with a control group of patients. METHODS: The records of all patients experiencing symptomatic intracerebral hemorrhage after carotid endarterectomy were reviewed and compared with data from 50 randomly selected patients who did not experience intracranial bleeding. Univariate analyses were performed, using the Fisher exact test for dichotomous data and the Student t test for continuous data. RESULTS: During a 6-year period, symptomatic intracranial hemorrhage developed in 11 (0.75%) of 1471 patients undergoing carotid endarterectomy, accounting for 35% of the 31 total perioperative neurologic events. Hemorrhage occurred a median of 3 days postoperatively (range, 0 to 18 days). Signs and symptoms included hypertension in all 11 patients, headache in 7 conscious patients (64%), and bradycardia in 6 patients (55%). Massive hemorrhage with herniation and death occurred in 4 patients (36%). Moderate hemorrhage developed in 5 patients (45%); 3 of these patients had partial recovery, and 2 had complete recovery. Petechial hemorrhage occurred in the remaining 2 patients (18%), 1 with partial and 1 with complete recovery. In comparison with the control group, there were no differences in respect to sex, indication for operation, smoking or diabetic history, and antiplatelet therapy or perioperative heparin management. Patients with intracranial hemorrhage were, however, younger, more frequently hypertensive, had a higher degree of ipsilateral and contralateral carotid stenosis, and had a higher rate of contralateral carotid occlusion. CONCLUSION: Intracranial hemorrhage occurs with notable frequency after carotid endarterectomy and accounts for a significant proportion of neurologic morbidity and mortality. Younger patients, hypertensive patients, and patients with severe cerebrovascular occlusive disease appear to be at greatest risk for the complication.

Age Factors↗
PubMed1988

The relationship of early hypertension following carotid endarterectomy to intraoperative cerebral ischemia.

The relationship between early hypertension following carotid endarterectomy, and intraoperative cerebral ischemia was investigated. Two measures of the adequacy of collateral cerebral circulation during carotid clamping were used: collateral cerebral perfusion pressure (delta P), and the ratio of collateral to ipsilateral cerebral vascular resistance (R/R). Change in blood pressure was measured by the ratio of mean early post to preendarterectomy pressure (P/P). Nitroprusside or nitroglycerin (NN) was used after endarterectomy to maintain systolic blood pressure less than 160 mmHg. The mean values for NN (n = 26) and no NN (n = 81) groups were: delta P = 30.0 and 40.2 mmHg (p less than 0.001); R/R = 1.93 and 1.24 (p less than 0.005); and P/P = 1.03 and 0.857 (p less than 0.001 p by unpaired t test). Linear regression analysis of the two measures of cerebral perfusion with the ratio of post-to preoperative blood pressure gave correlation coefficients between 0.629 and 0.841 with a probability that the slope of the regression line greater than 0 of less than 0.01. Low delta P and high R/R correlate with early postcarotid endarterectomy hypertension. These results support the hypothesis that one determinant of early post endarterectomy hypertension is inadequate collateral cerebral circulation during carotid clamping.

Aged↗
PubMed1989

Cervical wound hematoma after carotid endarterectomy.

Between 1974 and 1984, 1222 patients underwent carotid endarterectomy at a large community teaching hospital. Twenty-three (1.9%) of these patients required reexploration for hematoma at the endarterectomy site. We reviewed the records of these 23 patients with regard to the incidence of perioperative hypertension; the use of platelet-altering medication, heparin, protamine sulfate, and low molecular weight dextran; and the findings at reoperation. We also reviewed the records of 122 randomly selected patients who did not develop wound hematoma after carotid endarterectomy. The incidence of intraoperative and postoperative hypertension was significantly higher in the hematoma group than in the control group. The incidence of preoperative hypertension was not significantly different between the two groups. More hematoma patients received preoperative platelet-altering medication (43% versus 25%), and fewer received intraoperative protamine sulfate to reverse the effects of heparin (48% versus 66%), but these differences were not significant. This study emphasizes the importance of careful hemodynamic monitoring during and immediately after carotid endarterectomy.

Aged↗
PubMed2004

Carotid endarterectomy: who is the high-risk patient?

The role of carotid endarterectomy in the prevention of stroke was validated by two randomized clinical trials, the North American Symptomatic Carotid Endarterectomy (NASCET) and the Asymptomatic Carotid Atherosclerosis Study (ACAS). However, these trials excluded patients at high risk for perioperative stroke and other morbidity, raising concerns for the applicability of the trial results to the general population. Some have also suggested these "high-risk" patients are better suited for carotid artery stenting with the belief that stenting has lower morbidity and mortality. In this article, we review many of the commonly accepted high-risk factors for carotid endarterectomy (CEA) and examine their outcomes. High-risk patients are more common than generally believed and their outcomes may be the same with carotid endarterectomy as it is with carotid stenting. Truly "high-risk" patients with shortened life expectancy are best served with no intervention.

Age Factors↗
PubMed2002

Which Doppler velocity is best for assessing suitability for carotid endarterectomy?

OBJECTIVE: To evaluate which velocity, or combination of velocities, from carotid Doppler ultrasonography (DU), achieved the closest agreement with an assessment of suitability for carotid endarterectomy from intra-arterial angiograms (IAA). METHODS: We prospectively collected data from 148 consecutive patients (288 carotids), who had DU and IAA (blinded assessment) before possible carotid endarterectomy. We halved our data by randomly selecting the left or right carotid artery for each patient. We used one half to calibrate our DU results to IAA (to decide which velocity corresponded with what degree of angiographic stenosis). Using this analysis, each artery in the other half of the data was defined as suitable (80-99% stenosed) or unsuitable for carotid endarterectomy. We evaluated every individual, and combination of, velocities (strategies) to see which gave the closest agreement with IAA. RESULTS: Of all 80 strategies, six resulted in better agreement than others of the same or lower complexity. Five of these strategies gave better agreement than the internal carotid artery peak systolic velocity (ICA PSV) (kappa 0.78), but the improvement was small. CONCLUSION: Using the ICA PSV alone is adequate for assessing carotid stenosis before endarterectomy using DU, as long as the machine is calibrated to IAA. However, the addition of the ratio of the ICA PSV to the common carotid artery PSV adds only one further measurement, slightly increases the agreement with IAA, and would be reasonable to use on a daily basis.

Carotid Arteries↗
PubMed1992

Hypoxic ventilatory response and carotid endarterectomy.

Carotid endarterectomy is reported to abolish hypoxic ventilatory responsiveness. This effect is thought to be due to denervation or destruction of the carotid bodies by surgical exposure. The technique of carotid endarterectomy, however, does not require the sacrifice of these structures. Six patients who had bilateral carotid endarterectomy with careful preservation of the carotid bodies and their innervation were studied pre- and postoperatively with respect to hypoxic ventilatory responsiveness and the latter was taken as a measure of chemoreceptor activity. Five patients showed a weak or absent response to hypoxia before surgery. In four of these there was a significant increase in reactivity after the procedure (p less than 0.01 in one case, p less than 0.05 in three others). The fifth patient had a non-significant increase and the sixth had a normal response before and after surgery. Thus, loss of chemoreceptor function after bilateral carotid endarterectomy was not observed in this group of patients with preserved carotid bodies. The low ventilatory hypoxic sensitivity before surgery and its occasional increase after removal of the plaque suggests that atherosclerosis might well impair the microscopic blood supply to the carotid bodies, inducing sensor dysfunction but this hypothesis requires further investigation.

Aged↗
PubMed1997

Carotid eversion endarterectomy and reimplantation: a safe and simple technique to prevent acute thrombosis-occlusion and/or early and late restenosis.

The purpose of this report is to consider the technical aspects of carotid eversion endarterectomy and reimplantation into the common carotid artery for surgical treatment of atherosclerotic occlusive disease, in light of previous early and late results. In the past 2 years, the authors have more frequently used carotid eversion endarterectomy and reimplantation to minimize the risk of perioperative stroke due to acute occlusion-thrombosis, and the incidence of early and late restenosis. Some 88 patients underwent 95 carotid eversion endarterectomies and reimplantation (seven bilateral): 59 internal carotid arteries were surgically corrected for ischaemic symptoms while 36 patients were symptomless but presented with a haemodynamically significant stenosis at the internal carotid artery bifurcation. The ischaemic preoperative symptoms consisted of one or more transient ischaemic attack's in 39 patients (66%), amaurosis fugax in 15 (25%) and mild stroke in five (8%). Associated elongation of the internal carotid artery beyond the end of the plaque was present in 81 cases (85%). After freeing the internal carotid artery sufficiently beyond the distal limit of the lesion, the vessel was transected obliquely to its origin, the extramedial cleavage plane opened and the endarterectomized arterial wall everted beyond the natural end of the plaque, which was gently removed. The artery was dilated distally and finally reimplanted end-to-side into the common carotid artery, 1-2 cm or more above the original site. This technique has provided excellent early and late results: no deaths, no acute thrombosis-occlusion, no minor or major stroke occurred perioperatively. No restenosis, no symptomless or symptomatic late occlusion was found during late follow-up (mean 28 (range 6-44) months). The performance of this vascular technique must be encouraged and recommended because of its speed, effectiveness and success. Carotid eversion endarterectomy and reimplantation should be performed routinely when the internal carotid artery is elongated.

Aged↗
PubMed1997

Selective shunting with EEG monitoring is safer than routine shunting for carotid endarterectomy.

The purpose of this study was to identify whether EEG is an adequate method of monitoring cerebral perfusion during carotid endarterectomy and of determining the need for use of an indwelling shunt. A retrospective review of 305 carotid endarterectomies comparing the results of routinely shunted patients with patients selectively shunted based on EEG monitoring, was carried out. Of the carotid endarterectomies, 92 (30%) were routinely shunted and 213 (70%) were selectively shunted. In the selectively shunted group, 34 (16%) subsequently required shunting. The major stroke rate in the routinely shunted group was 4.4% ((4) cases) and in the selectively shunted group was 0.5% ((1) stroke). Three of the four major strokes in the routinely shunted group were embolic in origin and one was caused by acute thrombosis. The only major stroke in the selectively shunted group was from intracerebral hemorrhage. In conclusion EEG monitoring is a safe and reliable method to determine the need for shunting during carotid endarterectomy. Routine non-selective use of a shunt may increase the risk of perioperative stroke from arterial injury and associated thromboembolism.

Aged↗