The Anatomy of the Circle of Willis Is Not a Strong Enough Predictive Factor for the Prognosis of Cross-Clamping Intolerance during Carotid Endarterectomy.

Piotr Myrcha,Witold Woźniak,Andrzej Lewczuk,Dariusz Koziorowski,Mariusz Kozak,Dawid Siemieniuk,Maciej Jakuciński,Dorota Różański

doi:10.3390/jcm9123913

Piotr Myrcha, Witold Woźniak + Show 6 more

Open Access

https://doi.org/10.3390/jcm9123913

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Journal: Journal of Clinical Medicine	Publication Date: Dec 2, 2020
Citations: 8	License type: CC BY 4.0

Affiliation: Medical University of Warsaw

Abstract

Carotid endarterectomy (CEA) is safe and effective in reducing the risk of stroke in symptomatic severe carotid artery stenosis. Having information about cross-clamping (CC) intolerance before surgery may reduce the complication rate. The purpose of this study was to assess the usefulness of magnetic resonance angiography (MRA) and magnetic resonance angiography perfusion (P-MR) in determining the risk of CC intolerance during CEA. Material and methods: 40 patients after CEA with CC intolerance were included in Group I, and 15 with CC tolerance in Group II. All patients underwent MRA of the circle of Willis (CoW), P-MR with or without Acetazolamide; P(A)-MR in the postoperative period. Results: CoW was normal in the MRA in three cases (7.5%) in Group I, and in eight (53%) in Group II. We found P-MR abnormalities in all patients from Group I and in 40% from Group II. Using a calculated cut-off point of 0.322, the patients were classified as CC tolerant with 100% sensitivity or as CC intolerant with 95% specificity. After evaluating P-MR or MRA alone, the percentage of false negative results significantly increased. Conclusion: The highest value in predicting cross-clamping intolerance is achieved by using analysis of P(A)-MR and MRA of the CoW in combination.

Highlights

Neurological complications during and after internal carotid artery (ICA) endarterectomy (CEA) occur as a result of intraoperative embolization, hypoperfusion during the ICA cross-clamping (CC), intracranial hemorrhage or hyperperfusion syndrome [1,2].The risk of intraoperative neurological complications is high in patients who do not tolerate CC, and extremely high in the case of acute thrombosis of the operated artery or repeated operations
The only pathology found in Group II was bilateral or unilateral lack of posterior communicating artery (PCoA)
The combined analysis of the results of PA-MR and magnetic resonance angiography (MRA) showed that the most important predictor of tolerance to CC is the combined result of PA-MR and MRA of intracranial arteries, and the W index calculated on their basis

Summary

Introduction

Neurological complications during and after internal carotid artery (ICA) endarterectomy (CEA) occur as a result of intraoperative embolization, hypoperfusion during the ICA cross-clamping (CC), intracranial hemorrhage or hyperperfusion syndrome [1,2]. The risk of intraoperative neurological complications is high in patients who do not tolerate CC, and extremely high in the case of acute thrombosis of the operated artery or repeated operations. Patients are unnecessarily selected for a shunt or for carotid artery stenting (CAS) even if they have contraindications. The purpose of this study was to preoperatively assess the risk of cerebral ischemia during carotid CC using different diagnostic tests. Our goal was to investigate factors affecting cerebral ischemia during carotid CC

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