Strategy Of Selective Shunting For Carotid Endarterectomy In Patients With Recent Stroke
*Vicki Sharma, Sachinder Hans, *Steve Vang
St John Ascension Hospital Macomb-Oakland, Warren, MI
OBJECTIVE(S): Routine shunting during carotid endarterectomy (CEA) for recent stroke is preferred by most surgeons although selective shunt placement is preferred for other indications of CEA. We evaluated the safety of selective shunting in patients with recent stroke. METHODS: A retrospective review of 104 consecutive CEA (group A) performed in patients with recent stroke at two teaching hospitals was conducted from 2000-2019. All patients had middle cerebral artery stroke with greater than 70% ipsilateral internal carotid artery (ICA) stenosis. During the same time interval, 1156 CEA's were performed for other indications (group B), remote stroke 34 patients, focal transient ischemic attack 368 patients and asymptomatic greater than 80% stenosis of the ICA 754 patients. A shunt was placed if patients exhibited symptoms of cerebral ischemia under cervical block anesthesia or if ischemic EEG changes were seen under general anesthesia. RESULTS: 104 patients (66 males) were in group A, ages ranging between 35 to 91 years (mean 69.8 +/- 10.7). 58 patients had a minor stroke and 46 patients had a moderate stroke. Postoperative major stroke occurred in 4 (3.8%) patients in group A; cerebral infarct (3) and intra-cerebral hemorrhage (1). In group B, 16 patients sustained major stroke (p 0.08). Postoperative MI (0 in group A, 2 in group B, p=1.00), permanent cranial nerve injury (0 in group A, 3 in group B, p 1.00), re-exploration of the neck for hematoma (0 in group A, 9 in group B, p 1.00) and seizures (4 in group A, 0 in group B, p 0.001) were observed. Out of 104 patients (group A), 16 (15.4%) patients undergoing CEA for recent minor-moderate stroke required shunt. Among 1156 patients undergoing CEA for other indications, 113 (9.8%) patients required shunt placement (p 0.09). CONCLUSIONS: Shunt requirement during recent stroke are similar to other indications for CEA. Patients undergoing CEA for recent stroke had similar incidence of postoperative neurological deficit, MI and cranial nerve injury as compared with other indications for CEA. There was a higher incidence of postoperative seizures and mortality in patients undergoing CEA for recent stroke compared to other indications of CEA.
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