The Occlusion and Shunt Times for Carotid Endarterectomy with Primary Closure, Patch Angioplasty, and Adjunctive Reconstructive Procedures

Abstract

This is a report of the carotid occlusion and shunt times utilized to perform carotid endarterectomy (CEA) with primary closure, patch reconstruction, and interposition bypass grafting. The times needed for two ancillary procedures, inversion plication repair of the endarterectomy-produced common carotid step and eversion plication shortening of the endarterectomized internal carotid artery, are also reported. Over 15 years, 1,326 primary CEAs were performed. In 144 (10.9%) of these a shunt was utilized. Reconstruction was by primary closure in 137 (10.3%); patching in 1,171 (88.3%), of which 903 (77.1%) were with autologous vein, 241 (20.6%) with Dacron, and 27 (2.3%) with polytetrafluoroethylene (PTFE); and interposition bypass grafting with reversed saphenous vein in 18 (1.4%). The carotid occlusion times for nonshunted CEAs, the shunt times, the occlusion times for arteriotomy and shunt placement and for shunt removal and closure, and the total operative times were prospectively recorded. Common carotid steps >2 mm were reconstructed in 92 (6.9%) of CEAs. The internal carotid was shortened in 63 (4.8%) CEAs. Both ancillary procedures were performed in 19 (1.4%) CEAs. The occlusion and total shunt times for all CEAs was 27.4 ± 6.7 min (m +1 s.d.). The mean shunt time plus two short occlusion times were 5 to 6 minutes longer than the mean occlusion times for nonshunted CEAs. The carotid occlusion time was 20.9 ±5.2 minutes for primary closure and 27.4 ±6.3 minutes for patch reconstruction (31% longer). The occlusion and shunt times for CEAs with each of the three patch materials were essentially identical. The occlusion times for patched CEAs without and with step reconstruction were 27.1 ±6.2 and 31.5 ±6.0 minutes, respectively (16% longer), and without and with shortening, 27.8 ±6.1 and 29.4 ±8.0 minutes, respectively (6% longer). Arteriotomy length correlated with occlusion and shunt times (p<0.001 for slope, r=0.41). The total operative time was 70.6 ±8.3 minutes for all CEAs. Perioperative stroke was not associated with occlusion time or shunt use. Patch reconstruction adds approximately 6 to 7 minutes to carotid occlusion time and total shunt time when compared with primary closure. Common carotid step repair adds approximately 4 minutes and internal carotid shortening 2 minutes to occlusion and shunt times. The increased occlusion times necessary for patch angioplasty and ancillary reconstructive procedures are relatively short and do not predispose patients to increased risk of perioperative stroke.