title: The selection for shunting in patients with severe bilateral carotid lesions.
abstract: Patients with severe bilateral carotid lesions (stenosis and contralateral internal carotid occlusion) are at high risk of having a stroke, and carotid endarterectomy has been proposed as the best treatment. In spite of improvements in surgical technique, this operation is still associated with significant perioperative complications (5-13%) which are frequently (up to 40%) correlated with intolerance to internal carotid artery clamping. For this reason, intraoperative cerebral monitoring able to accurately detect ischaemia during surgery would be useful. Reviewing our experience from the last 7 years in 74 patients operated on for stenosis and contralateral occlusion of the internal carotid artery, we found a 1.3% neurological morbidity and 1.3% mortality rate. Presenting symptoms included focal transient ischaemia attacks (TIAs) in 57 patients, stroke in 16 patients and two patients were asymptomatic. Half of these patients (37) were operated on under general anaesthesia with electroencephalogram (EEG) monitoring, stump pressure measurement and selective shunting. In this group, two patients (5.4%) sustained a postoperative stroke, one of which was fatal. The remaining 37 patients were operated on under local-regional anaesthesia with selective shunting on the basis of neurological deficit onset or loss of consciousness during the test clamp. There were no postoperative neurological complications in this group but one patient died of acute myocardial infarction on the 6th postoperative day. This experience suggests that it is possible to perform carotid endarterectomy in patients with severe bilateral lesions with a postoperative complication rate similar to that in patients with less complicated obstructive lesions if accurate intraoperative cerebral monitoring is used.
authors.affiliation: Department of Vascular Surgery, University of Rome, La Spienza, Italy.
authors.forename: E
authors.initials: E
authors.lastname: Sbarigia
authors.forename: F
authors.initials: F
authors.lastname: Speziale
authors.forename: M
authors.initials: M
authors.lastname: Colonna
authors.forename: M
authors.initials: M
authors.lastname: Taurino
authors.forename: L
authors.initials: L
authors.lastname: Rizzo
authors.forename: M
authors.initials: M
authors.lastname: Massucci
authors.forename: G J
authors.initials: GJ
authors.lastname: Massimi
authors.forename: P
authors.initials: P
authors.lastname: Fiorani
mesh_terms: D000328:Adult; D000368:Aged; D000768:Anesthesia, General; D000772:Anesthesia, Local; D001157:Arterial Occlusive Diseases / Q000601:surgery; D001794:Blood Pressure; D002545:Brain Ischemia / Q000209:etiology / Q000517:prevention & control*; D002339:Carotid Arteries / Q000601:surgery; D002340:Carotid Artery Diseases / Q000601:surgery*; D002343:Carotid Artery, Internal / Q000601:surgery; D016893:Carotid Stenosis / Q000601:surgery; D003250:Constriction; D004569:Electroencephalography; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods; D012307:Risk Factors