title: Immediate conversion to CAS after neurological intolerance at cross-clamping test during CEA: a preliminary experience.
abstract: OBJECTIVE
  The aim of this preliminary study is to evaluate the feasibility and efficacy of CAS as treatment option to endarterectomy when carotid shunt cannot be used safely.
  
  
  METHODS
  The medical records concerning 469 carotid stenosis treated between January 2006 and December 2009 were retrospectively reviewed, focusing on cross-clamp intolerance during CEA. Patients with cross-clamping intolerance were divided in two groups. Group 1: those that concluded the open procedure with the use of a shunt, and Group 2: those who experience immediate brain intolerance and coma and were immediately converted to an endovascular procedure. Mortality and neurological adverse event rate were compared between shunted CEA and cross-clamping intolerant cases converted into CAS. The secondary end-point was long-term survival.
  
  
  RESULTS
  Carotid cross-clamp intolerance occurred in 30 cases (8.7%). CEA with Pruitt-Inahara's shunt was performed in 17 cases with a perioperative neurological adverse event rate of 23.5%. In 13 cases limitations to shunting due to quick onset of coma and/or an unfavorable anatomy were encountered. In these 13 cases the open intervention was immediately converted into endovascular procedure. Technical success was achieved in all the converted to CAS cases (100%), with a perioperative neurological adverse event rate of 7.7% (P=0.35 between the two groups). No significant difference emerges comparing patient's survival between the cases
  
  
  CONCLUSIONS
  Nevertheless, the small dimension of this survey, immediate conversion to CAS resulted feasible with a lower risk of neurological adverse events if compared to CEA with shunt, and could be considered as an alternative to CEA when carotid shunt cannot be used safely.
authors.affiliation: IRCCS Istituto Auxologico Italiano, Milan, Italy.
authors.forename: P
authors.initials: P
authors.lastname: Guy Bianchi
authors.forename: V
authors.initials: V
authors.lastname: Tolva
authors.forename: I
authors.initials: I
authors.lastname: Dalainas
authors.forename: G
authors.initials: G
authors.lastname: Bertoni
authors.forename: L
authors.initials: L
authors.lastname: Cireni
authors.forename: S
authors.initials: S
authors.lastname: Trimarchi
authors.forename: V
authors.initials: V
authors.lastname: Rampoldi
authors.forename: R
authors.initials: R
authors.lastname: Casana
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017130:Angioplasty / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D016893:Carotid Stenosis / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D002533:Cerebral Angiography; D002560:Cerebrovascular Circulation; D002561:Cerebrovascular Disorders / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D003250:Constriction; D016894:Endarterectomy, Carotid / Q000009:adverse effects* / Q000401:mortality; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007558:Italy; D053208:Kaplan-Meier Estimate; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D012042:Registries; D012189:Retrospective Studies; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D018615:Ultrasonography, Doppler, Color