Contralateral carotid artery occlusion is not a contraindication to carotid endarterectomy even if shunts are not routinely used.
OBJECTIVE
Although controversial, carotid artery stenting (CAS) has been proposed as being safer than carotid endarterectomy (CEA) for patients with a contralateral internal carotid occlusion (CCO). Arguably, with a CCO, CAS should be even safer than CEA if a shunt is not used. Accordingly, we reviewed our experience with 2183 CEAs performed routinely without a shunt to evaluate the risk of CEA performed in a subset of 147 patients with a CCO.


METHODS
Between 1988 and 2011, 147 CEAs (111 men [75%], 36 women [25%]) were routinely performed without a shunt despite CCO. Of these patients, 76% were asymptomatic. CEAs were performed by seven surgeons using standard techniques (not eversion), with patients under general anesthesia and blood pressure maintained at >130 mm Hg. All patients received heparin (7500 U), and protamine reversal was routine. Median cross-clamp time was 20 minutes (range, 14-40 minutes).


RESULTS
Three neurologic events occurred ≤ 30 days (2.0%). One transient ischemic attack (TIA) occurred immediately, and one occurred on the first postoperative day due to occlusion of the endarterectomy site. One patient sustained an immediate stroke and died of a large computed tomography-documented atheroembolic shower.


CONCLUSIONS
Our data demonstrate the safety of CEA in the presence of a CCO, even when performed without a shunt. It is unlikely that the stroke or delayed TIA could be attributed to nonshunting or CCO. Even if so, the stroke and death rates would be lower than those previously reported for patients undergoing CEA in the presence of a CCO. This may be due to short cross-clamp times, careful technique, general anesthesia, and blood pressure support. Given these low adverse event rates, our experience refutes the assumption that patients with a CCO are at such a high risk for CEA that the only alternative is CAS.
Sarasota Vascular Specialists, affiliated with Florida State University Medical School, Sarasota, Fla.
Russell H
RH
Samson
Jennifer L
JL
Cline
David P
DP
Showalter
Michael R
MR
Lepore
Deepak G
DG
Nair
D000368:Aged; D000369:Aged, 80 and over; D016893:Carotid Stenosis / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D002560:Cerebrovascular Circulation; D016009:Chi-Square Distribution; D000075202:Contraindications; D016894:Endarterectomy, Carotid / Q000401:mortality; D005260:Female; D006801:Humans; D002546:Ischemic Attack, Transient / Q000209:etiology / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D018579:Patient Selection; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000209:etiology / Q000503:physiopathology; D013997:Time Factors; D016896:Treatment Outcome