Intraluminal Shunt Research Articles

Risk factors for carotid endarterectomy in the early period of stroke

The OBJECTIVE was to identify significant risk factors of complications after carotid endarterectomy in the acute period of ischemic stroke, thus improving the outcomes of surgical treatment of symptomatic internal carotid artery stenosis.METHODS AND MATERIALS. The results of treatment of 776 patients after carotid endarterectomy in the acute period of stroke operated in the State Budgetary Institution of Tuberculosis «Regional Clinical Hospital № 2» were subjected to the factor analysis. catamnesis of the disease was traced for at least one year from the surgical intervention.RESULTS. Repeated ispilatory stroke occurred in 13 patients. Significant factors were tortuosity of the target artery (OR, 6.94; 95 % cI=2.21–21.86; p=0.003), aneurysm in the tortuosity zone (OR, 138.5; 95 % cI=11.6–1643.1; p=0.001), the presence of an electric cardiac pacemaker in the patient (OR, 31.71; 95 % cI=2.69–373.84; p=0.05), and need for IcA resection (OR, 6.83; 95 % cI=2.1–21.48; p=0.004). The risk factor for contralateral stroke in the early postoperative period was the use of a temporary intraluminal shunt (OR – 35.86; 95 % cI=2.17–592.92; p=0.05). Tortuosity of the target artery (OR – 4.6; 95 % cI=1.1–18.3; p=0.017), the need for IcA resection and in the presence of complicated atherosclerotic plaque in the reconstruction area (OR – 6.84; 95 % cI=1.89–24.85; p=0.01) turned out to be the sig nificant risk of death in the immediate postoperative period.CONCLUSIONS. Significant risk factors for recurrent stroke and death after carotid endarterectomy performed in the acute period of stroke were the tortuosity of the target artery, an aneurysm in the tortuosity zone, the presence of an electric cardiac pacemaker in the patient and the need for IcA resection in the presence of complicated atherosclerotic plaque in the reconstruction zone. The only risk factor for contralateral stroke in the early postoperative period was the use of a temporary intraluminal shunt. Further large trials are needed to clarify the obtained results.

393 Cerebral Oximetry Using the USIC Protocol Is a Reliable Tool for Indicating Selective Intraluminal Shunting During Carotid Endarterectomy

INTRODUCTION: Indication to selective shunting during carotid endarterectomy (CEA) is based on monitoring during the procedure. Cerebral oximetry (CO) using near-infrared spectroscopy (NIRS) is one of the monitoring tools but no clear cut off value for an intraluminal shunt insertion has been established. METHODS: 125 patients underwent CEA under LA and were monitored clinically through the whole procedure. The patients also underwent bilateral NIRS monitoring during the surgery. During the monitoring period, we first clamped the external carotid artery (ECA), and after a 1 minute delay followed by clipping the internal carotid artery (ICA). The decrease in the cerebral oximetry values was analyzed separately after selective ICA clipping (ÚstÍ Selective Internal carotid artery Clamping “USIC” protocol). The decision to use a shunt was based solely on clinical symptomatology but the NIRS data were recorded and analyzed. All patients underwent DWI before and after CEA. RESULTS: One hundred and six patients (85%) underwent CEA without clinical deterioration while 19 patients (15%) clinically deteriorated during surgery. The mean drop in the cerebral oximetry after selective ICA clamping in clinically stable patients was 6% while in patients with clinical deterioration the NIRS decreased by 15% (p < 0.05). When we set the cut-off value for selective shunting as a 10% decrease of the ipsilateral cerebral oximetry after selective ICA clamping, the sensitivity of the technique was 100% and the specificity 83%. CONCLUSIONS: Our study showed that a 10% decrease in the ipsilateral brain tissue oximetry after selective cross-clamping the ICA provides a reliable cut-off for selective shunting during CEA. More, bilateral NIRS monitoring allows differentiation between systemic or local events leading to brain hypoxia.

Prospective single-center study on the reliability of ipsilateral cerebral oximetry using near-infrared spectroscopy as a predictor for selective shunting during carotid endarterectomy.

Many techniques are available for the intraoperative assessment of brain perfusion during carotid endarterectomy, such as carotid stump pressure, near-infrared spectroscopy, somatosensory evoked potentials, transcranial Doppler, electroencephalography, and clinical assessment. The decision for selective carotid shunt insertion is dependent on clinical deterioration or the detection of cerebral hypoperfusion after cross-clamping of the internal carotid artery. Monitoring cerebral oximetry using near-infrared spectroscopy is a noninvasive technique for cerebral oxygen saturation measurement, reflecting changes in cerebral blood flow during carotid endarterectomy. The aim of this study was to evaluate the reliability of near-infrared spectroscopy as a predictor of selective shunting during carotid endarterectomy. In total, 47 conventional carotid endarterectomy surgeries were performed at our hospital between March 2016 and December 2021. All surgeries were performed under a regional cervical block supplemented with local infiltration anesthesia. All patients were monitored by cerebral oximetry using bilateral near-infrared spectroscopy probes and clinical assessment through communication with the patient (numerical, visual, and verbal) to indicate a selective shunt. Near-infrared spectroscopy values were recorded before and after internal carotid cross-clamping and after declamping. Any decrease in ipsilateral cerebral oximetry-near-infrared spectroscopy values equal to or more than 20% from the pre-clamping baseline reading associated with deterioration in neurological status (hemiparesis, aphasia, or deterioration in level of consciousness) after internal carotid artery cross-clamping was considered an indication for intraluminal carotid shunting. After internal carotid artery cross-clamping, 5 of 47 patients (10.6%) developed a significant drop in cerebral oxygen saturation associated with obvious clinical assessment deterioration in verbal communication and weakness in contralateral arm power. A Pruitt-Inahara carotid shunt was subsequently inserted, and 42 patients remained stable throughout surgery. The average decline in ipsilateral near-infrared spectroscopy values was 23.8% in patients with clinical deterioration. The average decline was 8.6% in patients who remained stable. Monitoring ipsilateral cerebral oximetry using near-infrared spectroscopy is an easy and reliable method for indicating selective shunting during carotid endarterectomy. A 20% decrease in ipsilateral brain tissue oximetry after internal carotid artery cross-clamping provides a reliable cut-off value for selective intraluminal carotid shunting during carotid endarterectomy.

Comparing carotid endarterectomies with or without shunting in symptomatic and asymptomatic patients

BackgroundRecent research shows that placement of an intraluminal shunt during a carotid endarterectomy (CEA) can be associated with postoperative complications. Therefore, we compared CEA operations with or without shunting to further analyze their clinical outcomes. MethodsFrom the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, 13,736 cases between 2016 and 2019 were analyzed to compare adult symptomatic and asymptomatic carotid stenosis patients who underwent a CEA operation, with or without shunt placement. ResultsRates of stroke with a neurological deficit (p = 0.012), myocardial infarction (p = 0.021), and urinary tract infection (p = 0.030) were higher among symptomatic patients with shunting. Multivariate logistic regression revealed that risk of CNI was higher among both symptomatic (93.63%, p < 0.001) and asymptomatic (69.58%, p = 0.001) patients with shunting, irrespective of confounding variables. ConclusionShunting was found to be associated with higher rates of postoperative complications in both symptomatic and asymptomatic patient populations.

3615 consecutive carotid endarterectomies without intraluminal shunt

3615 consecutive carotid endarterectomies without intraluminal shunt

Intraoperative neurophysiological monitoring during urgent surgical extracranial internal carotid artery recanalization

ObjectiveThe clinical outcome of surgical extracranial internal carotid artery (eICA) recanalization may be adversely affected by intraoperative ischemia. Median nerve somatosensory evoked potential (SEP) amplitude correlates well with cerebral blood flow.Our study presents the value of intraoperative SEP and selective shunting in the prevention of intraoperative ischemia development during urgent eICA recanalization. MethodsProspective recruitment of patients with acute unilateral eICA occlusion. All underwent surgical recanalization with intraoperative monitoring of scalp median SEPs. Preoperative clinical findings, cerebral collaterals, and 3 month functional outcome were evaluated. ResultsThe cohort consisted of 33 patients. Intraoperative SEP amplitude decreased significantly in 6 (18.2%). An intraluminal shunt was inserted twice (6.1%), surgical complications occurred in 6 (18.2%), intracerebral hemorrhage was not found.Favorable outcome 3 months after surgery according to the modified Rankin scale (mRS 0–2) was achieved in 28 (84.8%), 3 patients died (9.1%). ConclusionsIntraoperative SEP during urgent eICA recanalization seems to be beneficial.Thanks to the effective measure based on the intraoperative SEP changes, the clinical outcome in four(12.1%) could be positively affected. SignificanceThe results suggest that selective shunting based on intraoperative median SEPs may prevent intraoperative ischemia and may improve overall outcome of urgent eICA recanalization.

TCD monitoring of cerebral blood flow

Transcranial Doppler monitoring of intracranial blood flow during carotid endarterectomy, carotid angioplasty with stenting, surgical management of intracranial aneurysms, coronary artery bypass grafting, and thrombolysis of middle cerebral artery (MCA) occlusions is important because it enables recording of the flow in the MCA in real time. An adequate blood flow through the MCA during carotid endarterectomy allows for selective use of an intraluminal shunt (or the decision to operate without it) and timely identification of cerebral hyperperfusion, vasospasm, hypoperfusion, and cerebral microembolisms as well as recanalization of the cerebral artery, thus minimizing postoperative neurologic complications such as stroke or cognitive dysfunction.

EFFECT OF INTRA LUMINAL SHUNTS IN OFF PUMP CORONARY BY PASS GRAFTING ON LONG TERM GRAFT PATENCY

The intraluminal coronary shunts (ILS) in OPCAB allow easier, safer, more accurate anastomosisand better myocardial protection by maintaining distal coronary perfusion during beatingheart coronary revascularization. This was retrospectively study on sixty patients at MaadiMilitary Medical Campus who had OPCAB using ILS; Multislice CT and coronary angiographywere performed after one year of surgery to assess the graft patency. The total numberof grafts was 118, 60 were LIMA (50.8%) and 58 were SVG (49.2%). Post operatively sevenpatients (11.7%) had MI, two patients (3.3%) had wound infection, one patient (1.7%) hadprolonged ventilation>24hours, and one patient (1.7) had perioperative intra- aortic balloonpump.By coronary angiography; 102/118 grafts (86.4%) were patent, 6 had significant stenosis(>50%) and 10 grafts (8.5%) were totally occluded. BY CT angiography; 101-grafts (85.6%)were patent, 7-grafts (5.9%) had significant stenosis and 10-grafts (8.5%) were totally occluded,but without significant difference between results of coronary angiography, and CT angiography(p>0.05).The results by using ILS during OPCAB was safe and showed very much accepted graft patencyone year after OPCAB compared to the studies looked for graft patency after OPCABbut using different methods to achieve bloodless field during anastomosis like snaring andbulldogs, CT angiography is a good modality in terms of follow up after CABG it was a noninvasivetechnique needs no hospital admission, short examination time and it has high sensitivityand specificity.

Abrupcija na polazištu zajedničke karotidne arterije bez neurološkog deficita

Objective: In this case, we present a patient who despite iatrogenic common carotid artery disruption had no neurological impairment after vascular reconstruction. Case report: During the neck dissection in a young patient a complete abruption of the common carotid artery occurred. Median sternotomy was done for proximal bleeding control. Vascular reconstruction was done using temporary carotid shunting. The patient had no neurological consequences afterward. Conclusion: The lesion of major neck vessels is one of the most severe complications during the surgery which must be dealt with as soon as possible in best way in order to avoid permanent brain damage. In situations of iatrogenic lesions of major neck arteries heparin admission, which is usually normal therapy during vascular reconstruction, is not an option due to abrupt and uncontrollable bleeding. Thus, establishing surgically proximal and distal vascular control over the bleeding artery by vessel clamping and urgent placing of temporary intraluminal carotid shunting and best medical intraoperative therapy in this critical period of surgery might be the crucial therapeutic moment for brain protection.

Gender differences in coronary artery diameters and survival results after off-pump coronary artery bypass (OPCAB) procedures.

BackgroundCardiovascular disease is still the leading cause of death among men and women. The gender related survival differences following off-pump surgery was the subject of the study with relation to coronary arteries diameters according to sizes of intraluminal shunts applied during surgery.MethodsWe retrospectively collected data of 2,772 patients who were referred for surgical revascularization in our department between 2010 and 2018 with mean follow up period of 76 months. Patients underwent coronary artery bypass grafting with off-pump technique (OPCAB) with intraluminal shunts application during each anastomosis.ResultsThe multivariate Cox’s proportional hazards model revealed male sex as significant all-cause mortality risk factor [hazard ratio (HR) =4.62; 95% confidence interval (CI): (3.12–6.83)]. The survival proportion was significantly lower in male than female (73% vs. 94%; P<0.0001) within 130 months of follow up despite favorable results of coronary artery diameters. Mean ± standard deviation (SD) diameters of coronary arteries measured by shunts applied during off-pump revascularization were 1.81±0.28 vs. 1.7±0.26 mm (P<0.0001) for left anterior descending artery (LAD) anastomosis, 1.78±0.27 vs. 1.71±0.29 mm (P<0.0001) for circumflex artery (Cx) anastomosis and 1.77±0.28 vs. 1.72±0.31 mm (P>0.05) for right coronary artery (RCA) anastomosis in men and women subgroups, respectively.ConclusionsFemale sex is associated with better overall late survival following surgical revascularization despite smaller diameters of coronary arteries in direct measurement with the use of intraluminal shunt application.

Selective internal carotid artery cross-clamping increases the specificity of cerebral oximetry for indication of shunting during carotid endarterectomy.

An indication for selective shunting during carotid endarterectomy (CEA) is based on monitoring during a procedure. Cerebral oximetry (CO) using near-infrared spectroscopy (NIRS) may be a simple technique, but its relevance during CEA, especially with respect to cutoff values indicating shunt implantation, still needs to be elucidated. One hundred twenty five patients underwent CEA under local anesthesia (LA) and were monitored clinically throughout the whole procedure. The patients were also monitored using bilateral NIRS probes during surgery. The NIRS values were recorded and evaluated before and after selective cross-clamping, firstly by the external carotid artery (ECA), followed by the internal carotid artery (ICA). The decrease in the ipsilateral CO values, with respect to the indication of shunting, was only analyzed after selective cross-clamping of the ICA. The decision to use an intraluminal shunt was solely based on the neurological status evaluation after ICA cross-clamping. One hundred five patients (85%) were stable throughout the CEA, while 20 patients (15%) clinically deteriorated during surgery. The mean drop in the CO after selective ICA clamping in clinically stable patients was 6%, while in patients with clinical deterioration, the NIRS decreased by 14.5% (p < 0.05). When the cutoff value for selective shunting was set as a 10% decrease of the ipsilateral CO after selective ICA clamping, the sensitivity of the technique was 100% and the specificity 83.0%. Our study showed that a 10% decrease in the ipsilateral brain tissue oximetry after selective cross-clamping the ICA provides a reliable cutoff value for selective shunting during CEA. Despite the availability of a variety of monitoring tools, the NIRS may be an easy, reliable option, especially in the scenario of acute CEA in general anesthesia.

Modified Method of Eversion Carotid Endarterectomy in Patients with Extensive Atherosclerotic Disease Of Carotid Bifurcation: Short-term Results

Introduction: Performing eversion endarterectomy some difficulties arise. Firstly, it requires a great deal of coherence between the work of the surgeon and the first assistant, as well as a great experience of the latter. Secondly, in some cases, there are difficulties in visualizing the distal margin of the intima: in the absence of a rigid skeleton, the soft unchanged artery walls after removal of the plaque subside, making it difficult to visualize possible fragments of the intima. Thirdly, the cost of the error is high: with a random de-version, repeated eversion turns out to be impossible. It should be noted that the use of an eversion technique becomes difficult to implement, and sometimes impossible, with extended stenosis, since a very high allocation of the ICA is required, which increases the invasiveness of the operation and the difficulty of access. With prolonged stenosis, the carotid endarterectomy remains the option of choice. The modification used eversion carotid endarterectomy combines the advantages of both methods, and also eliminates the limitations of the carotid endarterectomy and eversion carotid endarterectomy. Methods: The study included 64 patients: 33 underwent eversion carotid endarterectomy (I group), and 31 - modified eversion carotid endarterectomy (II group). In 100% of cases, the intervention was performed under endotracheal anesthesia. Brain perfusion and the need for an intraluminal shunt were assessed using cerebral oximetra and retrograde pressure in the internal carotid artery. Exclusion criteria from the study: patients with a mouth injury of the ICA (plaque < 2 cm), patients with a contralateral occlusion of the ICA, patients with stroke in ischemic type in the acute period. Results: In our study, there were no cases of using a glove shunt. There were no hospital lethality, strokes, cases of transient ischemic attack and injuries of the cranial nerves in both groups. In group I, the clamping time of the internal carotid artery was 19.21 ± 1.47 minutes, versus 14.94 ± 1.39 minutes, p < 0.05 in group II, respectively. The patient's stay in the ICU in both groups did not exceed 1 day. In all patients, the wound healed by first intention. The average hospital stay did not exceed 6 days in both groups. Conclusion: The use of a modified eversion carotid endarterectomy technique can reduce the clamping time of the internal carotid artery and, as a consequence, reduce the time of cerebral ischemia in patients with common lesions of the common carotid artery bifurcation. Disclosure: Nothing to disclose

Outcome of Near-Infrared Spectroscopy–Guided Selective Shunting During Carotid Endarterectomy in General Anesthesia

To analyze the outcome of near-infrared spectroscopy (NIRS)-guided selective shunting during carotid endarterectomy and the procedural outcome. In this retrospective single-center study, patients undergoing carotid endarterectomy in general anesthesia and receiving bihemispheric NIRS as single neuromonitoring tool between January 2009 and January 2014 were included. Shunting was applied if the reduction in the NIRS values after cross-clamping on the ipsilateral side exceeded 15%. Patients with contralateral occlusion of the internal carotid artery (ICA) were excluded, as were patients operated on by surgeons performing routine shunting. All patients underwent intraoperative angiography after vessel recanalization. NIRS trend was available in 441 patients. Twenty-eight were excluded from this study (14 due to preference for general shunting, 13 due to contralateral ICA occlusion, and 1 due to intraoperative ICA occlusion), resulting in a final sample of 413 patients. We observed a >15% drop in NIRS values on the ipsilateral side in 29 (7%) patients. Accordingly, an intraluminal shunt was placed into the ICA. Shunting was not performed in 384 patients (<15% drop in NIRS values). Interestingly, the NIRS values on the contralateral side were significantly elevated after cross-clamping compared with baseline in the group without shunt (P<0.0001). On the contrary, patients requiring an ICA shunt revealed a statistically significant reduction in the rSO2 on the contralateral side compared with the baseline (after ipsilateral clamping) (P=0.047). Three patients overall suffered a stroke, all of whom were in the no-shunt group (combined stroke rate of 0.8% [3/384] with no significant intergroup difference). There was no difference in morbidity factors between the two groups. However, surgical revision after intraoperative angiography was significantly more frequent in the shunt group (17.2%, 5/29) versus the no-shunt group (6%, 23/384), (P<0.037). An NIRS-guided selective shunting strategy was associated with excellent clinical outcomes and has the potential to identify patients at risk for hypoperfusion during the clamping period. However, a potentially shunt-associated higher rate of requiring local revisions (due to flaps, twisting, stenosis, and kinking) in ICA was observed. Additional studies are needed to further refine cut-off values for NIRS, indicating the need for shunting.

The effect of cerebral oximeter use on the shunt placement concerning carotid endarterectomy surgery

Background:During carotid arterial endarterectomy (CAE) surgery, an intraluminal shunt is used to prevent hypoperfusion, which can be caused by a cross-clamping cerebral ischemia. However, routine shunt use is not recommended. Various cerebral monitoring techniques are used to determine the need for shunt placement. In this study, retrospective analysis of data on the efficacy of cerebral oximetry in the decision of shunt use during elective CAE surveys was planned.Materials and Methods:We collected data on 68 patients operated under general anesthesia between December 2016 and December 2017. Patients were evaluated for near infrared spectrometry (NIRS) and stump pressure values and whether shunt was placed or not.Results:Eight (11.7%) patients were shunting. NIRS value after cross-clamping was lower in patients with shunt. Stump pressure values were below 40 mmHg.Conclusions:Cerebral monitoring in elective CAE operations has great importance in determining the necessity of using intraluminal shunt to reduce the complications that may occur.

The Choice of the Type of Anesthesia for Carotid Endarterectomy (Review)

The article summarizes the international experience of using different types of anesthesia for the surgical treatment of carotid artery lesions. The anesthesiology support of surgery on the carotid basin includes general and combined anesthesia of various types. The regional anesthesia is a separate field in the carotid surgery. The paper presents the advantages and disadvantages of each anesthetic technique. The recent publications show the superiority of regional anesthesia in terms of its cost-effectiveness, less frequent use of temporary intraluminal shunt, the possibility to constant monitoring of patient’s neurological status throughout the operation, and lower incidence of neurologic and cardiac complications. Complications of the regional anesthesia and the methods of their correction are described in detail. There is still no consensus about the choice of the optimal type of anesthesia for carotid endarterectomy, hence further large-scale randomized trials are needed.

Risk and Outcome after Simultaneous Carotid Surgery and Cardiac Surgery: Single Centre Experience.

Objective Carotid artery stenosis in patients undergoing open-heart surgery may increase risk and deteriorate outcome. The aim of the study was the analysis of risks and outcome after simultaneous carotid and cardiac surgery. Methods We retrospectively reviewed the medical records of 100 consecutive patients who underwent simultaneous carotid surgery and open-heart surgery during a 5-year period (from 2006 to 2010). Seventy patients were male and 30 female; the mean age was 70.9±7.9 years (median: 71.8 years). Seventy-three patients underwent coronary bypass grafting (CABG), 18 patients combined CABG and valve procedures, 7 patients CABG combined with other procedures, and 3 patients isolated valve surgery. More than half of patients had had bilateral carotid artery pathology (n=51) including contralateral carotid artery occlusion in 12 cases. Results Carotid artery patch plasty was performed in 71 patients and eversion technique in 29. In 75 cases an intraluminal shunt was used. Thirty-day mortality rate was 7% due to cardiac complications (n=5), metabolic disturbance (n=1), and diffuse cerebral embolism (n=1). There were no carotid surgery-related deaths. Postoperatively, transient cerebral ischemia occurred in one patient and stroke with mild permanent neurological deficit (Rankin level 2) in another patient. Conclusion Simultaneous carotid artery surgery and open-heart surgery have low risk. The underlying cardiac disease influences outcome.

Features of surgical treatment of ischemic heart disease in patients with the expressed dysfunction left ventricular

Objective: to study the effect of intraluminal coronary shunts to immediate results of surgical treatment of ischemic heart disease in patients at high surgical risk with a reduced fraction of left ventricular ejection. Materials and methods: a retrospective analysis of case histories of 96 patients with coronary heart disease and decreased ejection fraction of the left ventricle who underwent surgery coronary artery bypass grafting. The patients were divided into 2 groups: the study group included 47 patients operated in the parallel artificial blood circulation, which when performing the distal anastomoses used temporary intracoronary shunts; the control group comprised 49 patients, also operated in the parallel artificial blood, but when performing distal anastomoses did not use intracoronary shunts. Monitoring of patients was performed until 12 months after surgery. Results: both groups of patients were matched for clinical and demographic indicators. In the analysis of intraoperative and postoperative period revealed the difference in the incidence of cardiac arrhythmias, other parameters were comparable. Conclusions: thus, in patients with reduced ejection fraction left ventricular intracoronary shunts is advisable to use for reasons and not in all cases, operations myocardial revascularization in the parallel artificial circulation.

Coronary clamping versus shunting during off pump CABG, early experience and outcome

BackgroundThe aim of this study was the evaluation of safety and outcome of temporal clamping of coronary artery in comparison to intraluminal coronary shunting, during distal anastomosis in off-pump coronary artery bypass grafting (CABG). MethodsTo evaluate the early outcome of coronary clamping, we randomly compared the results of 25 patients submitted to coronary clamping using microvascular clamps during off-pump CABG (group A), with the results of another 25 patients had traditional intraluminal coronary shunting during same procedure (group B). All patients proved to have coronary artery disease with no difference between the groups in preoperative clinical variables. ResultsClamp group (A) had significant shorter operative time than shunt group (B); it was 224.2 ± 44.1 min in group (A) versus 250.4 ± 33.7 in group (B).Our new coronary clamp was applied in (93%) of target vessels but coronary shunt was implanted in (96%) of target vessels during distal coronary anastomosis.Clamp group (A) had low number of patients who required inotropic support (adrenaline > 0.15 μg/kg/min) > 24 Hours during perioperative period. The study showed two cases of mortality in both groups.At 6 months follow up; no difference between both groups was found, but late postoperative ejection fraction in group (A) was better, when compared to group (B). ConclusionsTemporal coronary clamping technique may be used as an applicable option to create a bloodless field during off-pump CABG surgery. It seems to be faster and cheaper than intraluminal shunting. Also, it has the same complications, mortality and ICU stay.

Интраоперационный тромбоз и реканализация внутренней о.нной артерии при проведении эверсионной каротидной эндартерэктомии с возникновением диссекции общей сонной артерии, потребовавшей установки стента, у пациента, получавшего двойную дезагрегантную терапию

In the literature, there are some reports of the carotid artery thrombosis cases after carotid endarterectomy performing. More often, thrombosis is detected in the early postoperative period and less commonly verified intraoperatively. Intraoperative carotid artery dissection is also a rare complication of carotid endarterectomy. Due to the small number of such complications cases occurrence, there is no uniform tactic for managing these patients. Some authors report the facts about appropriate using of operative intervention with dual disaggregant therapy or intraoperative heparin injection or other methods for reducing the risk of the operated artery segment thrombosis. The issues of using the intraluminal shunt in case of intraoperative detection of the collateral blood flow insolvency and are not solved. The question of intraoperative control of the patient's neurological status and prevention of embolic complications is not solved too. A clinical case study demonstrating a series of intraoperative complications is presented, including intraoperative thrombosis and subsequent recanalization of the distal section of internal carotid artery during eversion carotid endarterectomy operation and the occurrence of dissection of the common carotid artery after using the intraluminal shunt. The surgical tactics is shown in identifying the specified complications, the discussion of encountered problems is offered to find the way to solve and prevent them. In a proven clinical case, carotid endarterectomy was performed under local anesthesia, and the patient received double disaggregant therapy.

Carotid Endarterectomy

Carotid endarterectomy should be considered for patients with symptoms of focal cerebral ischemia, when it can be performed with a combined morbidity and mortality below the annual risk of stroke (5%). The experience with 815 carotid endartectomies perforformed from 1979 to 1992 is presented. There were 530 (65%) men and 285 (35%) women of ages from 34 to 82 (median 65); risk factors included diabetes mellitus 196 (24%), hypertension 554 (68%), and smoking 570 (70%). Clini¬cal presentation consisted of transient ischemic attacks 464 (57%), cerebral infarction with minimal neurological residual 228 (28%), stroke in evolution 2 (0.2%), and asymptomatic stenosis 121 (15%). By Sundts classification of medical risk the groups were: grade I, 106 (13%); grade II, 350 (43%; grade III, 357 (44%); grade IV, 2 (0.2%). All patients received endotracheal anesthesia. Thiopental (3-5 mg/kg) and lidocaine (1 mg/kg) were given for induction and at 15 minutes intervals during carotid cross-clamping. Intraluminal shunts were used in 14 (2%). A conventional (open) endarterectomy was performed in 379 (46%) and a limited endarterectomy (closed) in 436 (54%). Complications included 8 (1%) deaths, 24 (3%) developed a major neurological deficit that persisted, 24 (3%) had perioperative TIAs which resolved completely. Of the patients with preoperative neurological deficits, 32 (4%) recovered. Therefore, at one month after surgery, 782 (96%) were either as well or better than pre-operatively. Of 483 (59%) postoperative angiograms, 40 (5%) showed an internal carotid artery occlusion. Six of these patients developed an immediate postoperative cerebral infarction and one died. Non-neurologic complicalions were: cardiac 40 (5%), peripherail nerve 24 (3%), and local wound problems 16 (2%). A carotid endarterectomy can be performed safely when it is done with meticulous attention to detail and consistent surgical technique.