title: Longer time interval between carotid cross-clamping and shunting is associated with increased 30-day stroke and death rate.
abstract: BACKGROUND
  The benefit of carotid endarterectomy (CEA) in patients with a significant (>70%) (a)symptomatic stenosis has been proven thoroughly in major trials. It is unknown whether, after cross-clamping the carotid artery, the time interval between determination that a shunt is needed and the actual functioning of the shunt, defined as the need for shunt-to-shunt time (NST), influences 30-day morbidity and mortality rate after CEA.
  
  
  METHODS
  Experienced vascular surgeons performed 851 CEAs with a selective shunting protocol based on perioperative transcranial Doppler measurement and electroencephalographic findings, and data were analyzed retrospectively. The study included 156 shunted patients.
  
  
  RESULTS
  Longer NST was associated with an increase in the 30-day stroke/death rate. A binary logistic regression model was used to determine a 2-tailed P value of .004 and an odds ratio of 1.5/min increase of the NST. There was no influence on stroke-death rate of gender, age, symptomatic or asymptomatic stenosis, the use of a patch or not, or the number of periprocedural microembolic signals.
  
  
  CONCLUSIONS
  If CEA is performed with a selective shunting protocol, a longer NST increases the 30-day stroke/death rate. These results support a strong recommendation that shunt placement should be as quick as possible.
authors.affiliation: Department of Vascular Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands. p.p.wisman@umcutrecht.nl
authors.forename: P P
authors.initials: PP
authors.lastname: Wisman
authors.forename: R P Tutein
authors.initials: RP
authors.lastname: Nolthenius
authors.forename: S C
authors.initials: SC
authors.lastname: Tromp
authors.forename: J C
authors.initials: JC
authors.lastname: Kelder
authors.forename: Jean-Paul P M
authors.initials: JP
authors.lastname: de Vries
mesh_terms: D000368:Aged; D001783:Blood Flow Velocity; D016893:Carotid Stenosis / Q000150:complications / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D002560:Cerebrovascular Circulation; D003250:Constriction; D004569:Electroencephalography; D016894:Endarterectomy, Carotid / Q000009:adverse effects* / Q000401:mortality; D005260:Female; D006801:Humans; D020766:Intracranial Embolism / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality / Q000503:physiopathology; D016015:Logistic Models; D008297:Male; D009426:Netherlands; D016017:Odds Ratio; D012039:Regional Blood Flow; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D020521:Stroke / Q000209:etiology* / Q000401:mortality / Q000503:physiopathology; D013997:Time Factors; D016896:Treatment Outcome; D017585:Ultrasonography, Doppler, Transcranial