OBJECTIVE: To evaluate the prognostic value of angiographic criteria and internal carotid artery (ICA) stump pressure for shunt placement in carotid surgery under local anaesthesia. DESIGN: Prospective clinical trial at a university hospital. MATERIALS AND METHODS: In 120 patients a cerebral angiography was initiated before undergoing carotid surgery. Seventy-five percent of the patients were neurologically asymptomatic, 13% had transient ischaemic attacks and 12% suffered from previous strokes. The operation was exclusively performed under local anaesthesia and prior to cross-clamping the ICA stump-pressure was measured. A shunt was inserted only if hemispheric symptoms or unconsciousness occurred independent of the angiographic findings or stump pressure. RESULTS: In 23% (27/120) a shunt became necessary and significantly (p<0.001) more often when there was a cross-flow towards the contralateral hemisphere (12/20=60%) or if the contralateral ICA was occluded (9/13=69%). The sensitivity for not needing a shunt in case of cross-flow towards the side of operation was 91% (52/57) whereas the specificity was 35% (22/63). ICA stump-pressure was significantly reduced in patients requiring a shunt (31 mmHg) compared to those not needing a shunt (53 mmHg) (p<0.001), but no definitive threshold value was found determining the need for shunting. Intraoperatively, no persistent neurological complication developed. CONCLUSIONS: Angiographic cross-flow was a good, but not perfect predictor for the need of an intraoperative shunt.
OBJECTIVE: To evaluate the prognostic value of angiographic criteria and internal carotid artery (ICA) stump pressure for shunt placement in carotid surgery under local anaesthesia. DESIGN: Prospective clinical trial at a university hospital. MATERIALS AND METHODS: In 120 patients a cerebral angiography was initiated before undergoing carotid surgery. Seventy-five percent of the patients were neurologically asymptomatic, 13% had transient ischaemic attacks and 12% suffered from previous strokes. The operation was exclusively performed under local anaesthesia and prior to cross-clamping the ICA stump-pressure was measured. A shunt was inserted only if hemispheric symptoms or unconsciousness occurred independent of the angiographic findings or stump pressure. RESULTS: In 23% (27/120) a shunt became necessary and significantly (p<0.001) more often when there was a cross-flow towards the contralateral hemisphere (12/20=60%) or if the contralateral ICA was occluded (9/13=69%). The sensitivity for not needing a shunt in case of cross-flow towards the side of operation was 91% (52/57) whereas the specificity was 35% (22/63). ICA stump-pressure was significantly reduced in patients requiring a shunt (31 mmHg) compared to those not needing a shunt (53 mmHg) (p<0.001), but no definitive threshold value was found determining the need for shunting. Intraoperatively, no persistent neurological complication developed. CONCLUSIONS: Angiographic cross-flow was a good, but not perfect predictor for the need of an intraoperative shunt.
Authors: María J Estruch-Pérez; Angel Plaza-Martínez; Maria J Hernández-Cádiz; Juan Soliveres-Ripoll; Cristina Solaz-Roldán; María M Morales-Suarez-Varela Journal: Arch Med Sci Date: 2012-05-09 Impact factor: 3.318