Selective Shunting Research Articles

Operative Factors Associated with Severe Hypotension in the Postoperative Setting in Patients with Carotid Artery Endarterectomy

Background: Carotid endarterectomy is a recognized method for preventing stroke for both symptomatic and asymptomatic hemodynamically carotid artery stenosis. Hemodynamic depression is more frequently associated with carotid artery stenting, while postoperative hypertension and cerebral hyperperfusion syndrome are known frequent complications after carotid endarterectomy. Severe hypotension after carotid revascularization is associated with a higher risk of perioperative stroke, myocardial infarction, and death, with limited data existing regarding risk factors. This study aims to investigate intraoperative risk factors for severe hypotension after carotid endarterectomy. Methods: A total of 160 patients who underwent carotid endarterectomy were included in this study. Patients with other cardiac conditions that required concomitant cardiac surgery, patients with incomplete medical records, and patients considered high risk for surgery were excluded. Results: The incidence of severe hypotension was 30.6%. Patients with severe hypotension after carotid endarterectomy had a higher incidence of diabetes, moderate mitral valve regurgitation, a history of percutaneous coronary intervention, and higher operative times. Using logistic regression, temporary shunt insertion was independently associated with severe postoperative hypotension (OR = 2.26, 95% CI = 1.09–4.71, p = 0.029). Conclusions: This result favors the selective shunting strategy when performing carotid endarterectomies, especially for those patients with comorbidities predisposing to postoperative complications.

Utility of the turn-back supporting technique using a steerable intermediate catheter: illustrative case.

Selective shunt occlusion (SSO) for intracranial dural arteriovenous fistulas (DAVFs) is a safe and effective method that directly intercepts the shunted pouch from the affected sinus with minimal materials. However, it can be challenging to obliterate the shunted pouch if the microcatheter is not supported adequately. A 68-year-old woman presented with tinnitus and was diagnosed with multiple shunted DAVFs in the right transverse-sigmoid sinus (TSS) and the superior sagittal sinus (SSS). Although the entire sinus packing of the right TSS was performed, a follow-up angiography 7 months later revealed significant cerebral venous reflux due to occlusion of the left TSS and an increasing residual shunt flow in the venous pouch at the confluence of the SSS. A guiding catheter was introduced into the isolated sinus transvenously. Then, a steerable intermediate catheter (SIC) was manually steered into a hairpin shape and hooked on near the pouch prior to navigating a microcatheter into the fistula point. Finally, the fistula pouch was completely obliterated using only two coils under the adequate support of the turned-back intermediate catheter. The turn-back supporting technique using an SIC was useful in achieving SSO for DAVFs, providing both adequate support and guidance for the coaxial microcatheter. https://thejns.org/doi/10.3171/CASE24467.

A management algorithm for idiopathic intracranial hypertension in skull base meningoencephaloceles.

In this study, the authors assessed an algorithm for the diagnosis and management of idiopathic intracranial hypertension (IIH) in patients who had undergone surgical repair of skull base meningoencephaloceles presenting with spontaneous cerebrospinal fluid (sCSF) leakage. The authors conducted an institutional retrospective review of patients surgically treated for skull base sCSF leaks between 2014 and 2021. Opening pressure (OP) measurements were taken intraoperatively. The algorithm recommended a ventriculoperitoneal shunt (VPS) for high-risk patients (OP ≥ 30 cm H2O), 4 weeks of acetazolamide plus a 2-week washout and repeat lumbar puncture (LP) at 6 weeks for intermediate-risk patients (OP = 20-29 cm H2O), and repeat LP at 4-6 weeks for low-risk patients (OP < 20 cm H2O). Demographics, radiographic characteristics, management adherence, and outcomes were analyzed. Eighty patients with sCSF leakage were identified. The mean age was 51.9 years, and the mean body mass index was 36.3 kg/m2. The median follow-up was 8.3 months (IQR 3.3-19.7 months). The overall VPS rate was 15.0%. Three patients (3.8%) experienced acute recurrent leakage, and 3 (3.8%) developed remote recurrent leaks (mean time of 48.1 months). For the 50 patients with both intra- and postoperative OPs, the mean OPs were not significantly different (23.3 vs 23.0 cm H2O, respectively, p = 0.82). The mean variability between the two measurements was an absolute difference of 6.6 cm H2O. While 13 patients (26.0%) moved to a higher-risk category based on postoperative OP, 18 patients (36.0%) moved to a lower-risk category. Utilizing an algorithm of direct meningoencephalocele repair and selective shunting, acute and remote CSF leak recurrence rates were each 3.8%, and the VPS rate was 15.0%. These data provide further insight into CSF dynamics in this population and argue against the theoretical concern that CSF pressure will increase postrepair. Significant intraindividual variability suggests multiple LPs may be necessary before committing to invasive IIH treatment. Further work is necessary to determine the optimal IIH management strategy.

Additional outlet occlusion as an important factor in avoiding retreatment after transvenous embolization for cavernous sinus dural arteriovenous fistulas

BackgroundTransvenous embolization (TVE), such as selective shunt occlusion, is the first line treatment for cavernous sinus dural arteriovenous fistula (CSDAVF). Despite the favorable outcomes of TVE, some cases necessitating retreatment...

Selective Shunting in Carotid Endarterectomy Based on Circle of Willis Assessment Reduced Perioperative Neurologic Event and Stroke Rates

Selective Shunting in Carotid Endarterectomy Based on Circle of Willis Assessment Reduced Perioperative Neurologic Event and Stroke Rates

Non-Invasive Tools in Perioperative Stroke Risk Assessment for Asymptomatic Carotid Artery Stenosis with a Focus on the Circle of Willis.

This review aims to explore advancements in perioperative ischemic stroke risk estimation for asymptomatic patients with significant carotid artery stenosis, focusing on Circle of Willis (CoW) morphology based on the CTA or MR diagnostic imaging in the current preoperative diagnostic algorithm. Functional transcranial Doppler (fTCD), near-infrared spectroscopy (NIRS), and optical coherence tomography angiography (OCTA) are discussed in the context of evaluating cerebrovascular reserve capacity and collateral vascular systems, particularly the CoW. These non-invasive diagnostic tools provide additional valuable insights into the cerebral perfusion status. They support biomedical modeling as the gold standard for the prediction of the potential impact of carotid artery stenosis on the hemodynamic changes of cerebral perfusion. Intraoperative risk assessment strategies, including selective shunting, are explored with a focus on CoW variations and their implications for perioperative ischemic stroke and cognitive function decline. By synthesizing these insights, this review underscores the potential of non-invasive diagnostic methods to support clinical decision making and improve asymptomatic patient outcomes by reducing the risk of perioperative ischemic neurological events and preventing further cognitive decline.

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 &lt; 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.

Short-term outcomes after selective shunt during carotid endarterectomy: A propensity score matching analysis

Introduction and objectivesCarotid cross-clamping during carotid endarterectomy might lead to intraoperative neurologic deficits, increasing stroke/death risk. If deficits are detected, carotid shunting has been recommended to reduce the risk of stroke. However, shunting may sustain a specific chance of embolic events and subsequently incurring harm. Current evidence is still questionable regarding its clear benefit. The aim is to determine whether a policy of selective shunt impacts the complication rate following an endarterectomy. Material and methodsFrom January 2013 to May 2021, all patients undergoing carotid endarterectomy under regional anesthesia with intraoperative neurologic alteration were retrieved. Patients submitted to selective shunt were compared to a non-shunt group. A 1:1 propensity score matching (PSM) was performed. Differences between the groups and clinical outcomes were calculated, resorting to univariate analysis. ResultsNinety-eight patients were selected, from which 23 were operated on using a shunt. After PSM, 22 non-shunt patients were compared to 22 matched shunted patients. Concerning demographics and comorbidities, both groups were comparable to pre and post-PSM, except for chronic heart failure, which was more prevalent in shunted patients (26.1%, P=0.036) in pre-PSM analysis. Regarding 30-day stroke and score Clavien–Dindo≥2, no significant association was found (P=0.730, P=0.635 and P=0.942, P=0.472, correspondingly, for pre and post-PSM). ConclusionsIn this cohort, resorting to shunting did not demonstrate an advantage regarding 30-day stroke or a Clavien–Dindo≥2 rates. Nevertheless, additional more extensive studies are mandatory to achieve precise results concerning the accurate utility of carotid shunting in this subset of patients under regional anesthesia.

Short-term outcomes after selective shunt during carotid endarterectomy: a propensity score matching analysis

Introduction and objectivesCarotid cross-clamping during carotid endarterectomy might lead to intraoperative neurologic deficits, increasing stroke/death risk. If deficits are detected, carotid shunting has been recommended to reduce the risk of stroke. However, shunting may sustain a specific chance of embolic events and subsequently incurring harm. Current evidence is still questionable regarding its clear benefit. The aim is to determine whether a policy of selective shunt impacts the complication rate following an endarterectomy. Material and methodsFrom January 2013 to May 2021, all patients undergoing carotid endarterectomy under regional anesthesia with intraoperative neurologic alteration were retrieved. Patients submitted to selective shunt were compared to a non-shunt group. A 1:1 propensity score matching (PSM) was performed. Differences between the groups and clinical outcomes were calculated, resorting to univariate analysis. ResultsNinety-eight patients were selected, from which 23 were operated on using a shunt. After PSM, 22 non-shunt patients were compared to 22 matched shunted patients. Concerning demographics and comorbidities, both groups were comparable to pre and post-PSM, except for chronic heart failure, which was more prevalent in shunted patients (26.1%, P=0.036) in pre-PSM analysis. Regarding 30-day stroke and score Clavien–Dindo ≥2, no significant association was found (P=0.730, P=0.635 and P=0.942, P=0.472, correspondingly, for pre and post-PSM). ConclusionsIn this cohort, resorting to shunting did not demonstrate an advantage regarding 30-day stroke or a Clavien–Dindo ≥ 2 rates. Nevertheless, additional more extensive studies are mandatory to achieve precise results concerning the accurate utility of carotid shunting in this subset of patients under regional anesthesia.

Vascular bypass surgery in the treatment of extrahepatic portal hypertension in children (review)

In children with extrahepatic portal hypertension (EPHT), the most frequent and life-threatening complication is bleeding from varicose veins of the esophagus and stomach. Therefore, the main task of HSV treatment is to prevent bleeding from the veins of the upper gastrointestinal tract. The most effective treatment is portosystemic bypass surgery, with effectiveness of 94%97%. However, the use of these operations is limited precisely by a decrease in portal liver perfusion and development of portosystemic encephalopathy. This study aimed to analyze domestic and foreign publications devoted to the surgical treatment of portal hypertension and the development of portosystemic encephalopathy during the postoperative period. A systematic search was carried out in PubMed, Web of Science, Scopus, MEDLINE, eLibrary, RSCI, and Cyberleninka; 345 references were analyzed, 110 articles were reviewed, and 97 publications on the surgical treatment of portal hypertension were selected for the review. The development of portosystemic encephalopathy during the postoperative period often occurs after the imposition of total portosystemic bypass surgery. To reduce the risk of developing portosystemic encephalopathy, selective shunts have been developed, which to some extent preserve the PPP. With distal splenorenal anastomosis, the frequency of portosystemic encephalopathy is 10%15%. An intermediate position is occupied by a side-to-side splenorenal anastomosis, which has signs of selective surgery. The results of the analysis of literature sources showed that discussions are still underway regarding the choice of the optimal treatment strategy for patients with EPHT, place and role of endoscopic methods for the prevention of gastrointestinal bleeding, and mesoportal shunt in the treatment of patients with EPHT. Nevertheless, the majority of world experts consider mesoportal shunt to be the most optimal operation for the primary and secondary prevention of varicose bleeding and other HSV complications. If it is impossible to perform, selective bypass surgery of the distal splenorenal anastomosis can be an alternative to a mesoportal shunt.

Comparison of Methods for Monitoring Intra-operative Cerebral Perfusion in Patients Undergoing Carotid Endarterectomy with Selective Shunting: A Systematic Review and Network Meta-Analysis of Randomised Controlled Trials and Cohort Studies

Comparison of Methods for Monitoring Intra-operative Cerebral Perfusion in Patients Undergoing Carotid Endarterectomy with Selective Shunting: A Systematic Review and Network Meta-Analysis of Randomised Controlled Trials and Cohort Studies

Routine versus selective near-infrared spectroscopy-guided shunting during carotid eversion endarterectomy.

The aim of this study was to compare outcomes of routine shunting to near-infrared spectroscopy (NIRS)-guided shunting in patients undergoing eversion endarterectomy (EEA) under general anaesthesia. We retrospectively evaluated data of all patients undergoing EEA of the internal carotid artery (ICA) in our department from January 2011 until January 2019. Included were patients with EEA of the ICA and the patients were divided into 2 groups: selective-shunting group and routine-shunting group. Patients (i) with patch angioplasty during the surgery, (ii) undergoing surgery for restenosis and (ii) stenosis after radiation therapy, (iii) without recorded regional cerebral oxygen saturation trends, (iv) presenting with an emergency treatment indication and (v) operated upon by residents were excluded. In all patients, EEA was performed in general anaesthesia and under NIRS monitoring. One-to-one propensity score matching was used to compare EEA outcomes after routine shunting to NIRS-guided shunting. Primary end points were defined as perioperative stroke and in-hospital mortality after EEA. Routine and NIRS-guided selective shunting were applied in 340 (34.0%) and 661 (66.0%) patients, respectively. A total of 277 pairs were generated via propensity score matching. Fifty-eight (20.1%) from the selective-shunting group were intraoperatively shunted. Concomitant procedures were more frequently performed in the routine-shunting group [170 (61.4%) vs 47 (17.0%), 180 (65%) vs 101 (36.5%), and 60 (21.7%) vs 6 (2.2%), P < 0.001]. The perioperative stroke rate in the routine-shunting group was higher as well [11 (4.0%) vs 3 (1.1%), P = 0.022]. In-hospital death was overall 0.2% (n = 1). Multivariable logistic regression in the matched patient indicated age (odds ratio 1.050, 95% confidence interval 1.002-1.104, P = 0.046) and routine shunting (odds ratio 2.788, confidence interval 1.119-7.428, P = 0.032) as risk factors for perioperative stroke during EEA of the ICA. We found that, during EEA of the ICA, under general anaesthesia, NIRS-guided selective shunting was associated with a lower incidence of perioperative stroke than routine shunting.

Monitoring and Maintaining Cerebral Perfusion During Carotid Endarterectomy: Use of Selective Shunt Under NIRS and Root Pressure Guidance

Karotis arter cerrahisinde endarterektomi ve eversiyon metotları semptomatik veya asemptomatik hastalarda inme ve mortalite oranını azaltmaya yönelik uygulanan düşük riskli altın standart tedavi yöntemleridir. Serebral hipoperfuzyon ve iskeminin erken tespiti için yakın kızılötesi spektroskopi (NIRS) yöntemi ile rejyonel serebral oksijen saturasyonu (rSO2) ve karotis kök basıncı ölçümü yaygın kullanılan yöntemlerdir. Serebral hipoperfuzyonu engellemek ve serebral iskemi riskini azaltmak amaçlı en yaygın kullanılan yöntem intraoperatif şant kullanılmasıdır. Çalışmamızda karotis kök basıncı eşik değeri ≤40mmhg şant kullanımına karar verilen hastalarda, NIRS rSO2 değerindeki azalma, şant kullanımının peroperatif inme ve mortalite üzerine etkilerini araştırmayı amaçladık. 2018-2020 yılları arasında Kuzey Amerika semptomatik karotis endarterektomi çalışması (NASCET) kriterlerine göre %70-99 oranında darlık saptanan ve opere edilen 40 hasta retrospektif olarak değerlendirilmiştir. Şant kullanılan ve kullanılmayan grupta ipsilateral NIRS değerleri sırası ile ortalama klemp öncesi 70.33±8.40 ve 65.1±4.52, klemp konulduktan sonraki ilk dakikada 57.87±8.4 ve 62.01±4.6 saptandı (p&amp;lt;0.05). Çalışmamızda NIRS rSO2’deki ≥%15 düşme ile kök basıncı ≤40mmhg eşik değeri arasında iyi bir korelasyon olduğunu düşünmekteyiz. Bu değerler ile şant kullanım kararı verilen hastalarımızda peroperatif inme ve ölüm ile karşılaşılmamıştır. Ancak rSO2’deki düşmenin net bir sınır değerinin belirlenebilmesi için daha fazla prospektif ve çok merkezli çalışmalara ihtiyaç vardır.

Carotid Endarterectomy Surgeries: A Multimodality Intraoperative Neurophysiological Monitoring Approach.

Patients with untreated carotid artery stenosis remain at high risk for stroke. Carotid endarterectomy (CEA) is a surgical procedure for the treatment of symptomatic and severe asymptomatic carotid stenosis. A small percentage of patients who do not have good collateral circulation are at high risk of cerebral ischemia during the cross-clamping of the carotid artery. Aspects of CEA, such as cross-clamping and routine shunting, can also carry the risk of perioperative stroke through dislodgement of emboli causing thrombosis, therefore, selective shunting is highly recommended during the CEA procedure. A multimodality approach of intraoperative neurophysiological monitoring (IONM) techniques such as somatosensory evoked potential (SSEP) and electroencephalography (EEG) can be used to monitor cerebral perfusion throughout the duration of the surgery and to predict the need for a selective shunt after cross-clamping. Additional use of transcranial Doppler (TCD) in the multimodality approach can aid in visualizing the cerebral blood flow and detecting any microemboli that may also cause a stroke. A multimodality IONM approach has been reported as more sensitive and specific for predicting and minimizing any postoperative neurological deficits.

Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting).

Temporary interruption of cerebral blood flow during carotid endarterectomy can be avoided by using a shunt across the clamped section of the carotid artery. The shunt may improve the outcome. This is an update of a Cochrane review originally published in 1996 and previously updated in 2002, 2009, and 2014. To assess the effect of routine versus selective or no shunting, and to assess the best method for selective shunting on death, stroke, and other complications in people undergoing carotid endarterectomy under general anaesthesia. We searched the Cochrane Stroke Group Trials Register (last searched April 2021), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2021, Issue 4), MEDLINE (1966 to April 2021), Embase (1980 to April 2021), and the Science Citation Index Expanded (SCI-EXPANDED) (1980 to April 2021). We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform, and handsearched relevant journals, conference proceedings, and reference lists. Randomised and quasi-randomised trials of routine shunting compared with no shunting or selective shunting, and trials that compared different shunting policies in people undergoing carotid endarterectomy. Three independent review authors performed data extraction, selection, and analysis. A pooled Peto odds ratio (OR) and 95% confidence interval (CI) were computed for all outcomes of interest. Best and worse case scenarios were also calculated in case of unavailable data. Two authors independently assessed risk of bias, and quality of evidence using GRADE. No new trials were found for this updated review. Thus, six trials involving 1270 participants are included in this latest review: three trials involving 686 participants compared routine shunting with no shunting, one trial involving 200 participants compared routine shunting with selective shunting, one trial involving 253 participants compared selective shunting with and without near-infrared refractory spectroscopy monitoring, and the other trial involving 131 participants compared shunting with a combination of electroencephalographic and carotid pressure measurement with shunting by carotid pressure measurement alone. Only three trials comparing routine shunting and no shunting were eligible for meta-analysis. Major findings of this comparison found that the routine shunting had less risk of stroke-related death within 30 days of surgery (best case) than no shunting (Peto odds ratio (OR) 0.13, 95% confidence interval (CI) 0.02 to 0.96, I2 not applicable, P = 0.05, low-quality evidence), the routine shunting group had a lower stroke rate within 24 hours of surgery (Peto odds ratio (OR) 0.15, 95% CI 0.03 to 0.78, I2 = not applicable, P = 0.02, low-quality evidence), and ipsilateral stroke within 30 days of surgery (best case) (Peto OR 0.41, 95% CI 0.18 to 0.97, I2 = 52%, P = 0.04, low-quality evidence) than the no shunting group. No difference was found between the groups in terms of postoperative neurological deficit between selective shunting with and without near-infrared refractory spectroscopy monitoring. However, this analysis was inadequately powered to reliably detect the effect. There was no difference between the risk of ipsilateral stroke in participants selected for shunting with the combination of electroencephalographic and carotid pressure assessment compared with pressure assessment alone, although again the data were limited. This review concluded that the data available were too limited to either support or refute the use of routine or selective shunting in carotid endarterectomy when performed under general anaesthesia. Large-scale randomised trials of routine shunting versus selective shunting are required. No method of monitoring in selective shunting has been shown to produce better outcomes.

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.

Strategy of Selective Shunting for Carotid Endarterectomy in Patients with Recent Stroke

Objectives: The aim of this study is to evaluate the safety of selective shunting in patients with a recent stroke (&lt;8 weeks since incident) undergoing Carotid Endarterectomy (CEA).

Timing to Carotid Endarterectomy Affects Early and Long Term Outcomes of Symptomatic Carotid Stenosis.

The aim of this study is to evaluate early and long-term outcomes according to the timing to carotid endarterectomy (CEA) of symptomatic carotid stenosis. Consecutive CEAs with selective shunting for symptomatic carotid stenosis ≥50% performed between 2009 and 2020. Patients had acute neurological impairment on presentation, defined as <5 points on the National Institutes of Health Stroke Scale (NIHSS). We grouped patients according to time between index event and CEA: the first group was operated between 0 and 2 days, the second group between 3 and 7 days, the third group between 8 and 14 days and the last group after 15 days. Thirty-day neurological status improvement was defined as a decrease (≥1) in the 30-day NIHSS score versus NIHSS score immediately before surgery. Five hundred CEAs were performed. The perioperative combined stroke and mortality rate was 3.6% (18/500), representing a perioperative mortality rate of 0.2 (n=1) and stroke rate of 3.4% (n=17). Overall freedom from stroke was 95% at 1 year, 89 % at 6 years, and 88% at 10 years. Annual stroke rate was 0.6% after the 30-day period. Thirty-day improvement in neurologic status occurred in 103 patients (20.6%), while in 380 (76%) neurologic status was unchanged, and 17 (3.4%) experienced worsening of their neurologic status. Patients treated within 7 days from the index event had significant benefit (OR=2.6) in the 30-day neurological improvement versus those treated after 7 days from the index event. Timing to CEA <2 days increased significantly the risk of late stroke (OR=9.7). The ideal timing for performing CEA is between 3 and 7 days from the index event if NIHSS <5 as it is associated with the best rates of improvement in neurological status and durability in the long term. Very early CEA (<48 hrs) was associated with increased late stroke occurrence.

Outcomes of Carotid Endarterectomy with Primary Closure

Background: Cerebrovascular ischemic cases are 3rd leading cause of fatality and neurologic dysfunction in adults. Atherosclerotic lesions outside the carotid cranial circulation are main cause of cerebral ischemia in almost 10-20 percent cases and carotid endarterectomy (CEA) has been proved beneficial for patients with severe carotid artery stenosis to prevent acute cerebrovascular events. Current study is conducted to assess the short-term outcomes of carotid endarterectomy among patients in terms of morbidities and mortalities at our institution during the study period. Material and Methods: This cross-sectional analytical study was carried out at Combined Military Hospital, Rawalpindi during August 2019 to July 2021 to analyze the short-term outcomes of carotid endarterectomy (CEA) with primary closure. All the patients who underwent carotid endarterectomy (CEA) with primary closure during study duration were included in the study. Patients who received selective shunting if Electro Encephalogram (EEG) changes noted were excluded from study. Data was collected after taking verbal consent by using preformed questionnaire. Frequency of morbidities like bleeding, infection, stroke, transient ischemic attacks (TIA), myocardial infarction, repeat operation and revision with stent were noted within postoperative period of one month. Frequency of mortalities in one-month postoperative period among patients undergoing carotid endarterectomy was also calculated. Data was entered and analyzed by using SPSS version 22. Results: Total 198 patients who underwent carotid endarterectomy with primary closure during study duration were included in the study. Age range of the study participants was between 35 to 80 years. Male patients were 107 (54.04%). The comorbidities evaluated in the study participants showed that 172 (86.87%) patients were hypertensive and 73 (36.87%) has diabetes mellitus. The most frequent postoperative morbidities among patients were bleeding and repeat operation. Conclusion: It is concluded that carotid endarterectomy with primary closure is a safe and effective surgical means of stroke prevention.