A Prospective Nonrandomized Study on Carotid Surgery Performed under General Anesthesia without Intraoperative Cerebral Monitoring.
BACKGROUND
The purpose of this study was to assess our experience of carotid surgery habitually performed under general anesthesia without intraoperative intracerebral monitoring, and following a pre-established perioperative protocol, which includes extensive use of an intraoperative shunt (IOS).


METHODS
This study included 311 consecutive carotid operations performed over 32 months. This patient cohort represents 14% of our total experience in carotid surgery (2219 operations, major stroke/mortality rate: 1.4%). The IOS was inserted routinely in the presence of intraoperative blood pressure instability during cross-clamping and when the predictable clamping time might have exceeded 20 minutes. A moderate and stable hypertension was maintained throughout surgery without IOS.


RESULTS
Overall, 120 (38.6%) endarterectomies were performed with primary closure, 73 (23.5%) with eversion technique, 113 (36.3%) with patch angioplasty, and 5 (1.6%) with other techniques. Out of 113 patch angioplasties, 111 (98.2%) were performed with an IOS. This was utilized in only 3 cases of direct carotid reconstructions or other carotid endarterectomy techniques (1.5%). Overall, the IOS placement rate was 36.7%. Postoperatively, 2 major strokes (.64%), 2 minor strokes (.64%), 4 hyperperfusion syndromes (1.3%), and no mortality were recorded. No cases of cross-clamp ischemia/shunt-related perioperative strokes were observed.


CONCLUSIONS
The low perioperative stroke rate reported in this prospective study proves the advantages of wide use of IOS during carotid surgery. This coupled with a large experience in carotid surgery and close monitoring and support of blood pressure, are the major determinants of these results that demonstrate the low risk of shunt-related complications for surgeons who regularly utilize an IOS.
Department of Vascular Surgery, Sandro Pertini Hospital, Rome, Italy. Electronic address: f.desantis6@virgilio.it.
Francesco
F
De Santis
Department of Vascular Surgery, Sandro Pertini Hospital, Rome, Italy.
Cristina Margot
CM
Chaves Brait
Institute of Genetic Medicine, European Academy of Bolzano/Bozen (EURAC), Italy.
Cristian
C
Pattaro
Department of Anaesthesiology, Sandro Pertini Hospital, Rome, Italy.
Vladimiro
V
Cesareo
Department of Vascular Surgery, Sandro Pertini Hospital, Rome, Italy.
Vincenzo
V
Di Cintio
D000368:Aged; D000369:Aged, 80 and over; D000768:Anesthesia, General / Q000009:adverse effects; D017130:Angioplasty / Q000379:methods; D002339:Carotid Arteries / Q000601:surgery*; D002560:Cerebrovascular Circulation; D002985:Clinical Protocols; D016894:Endarterectomy, Carotid; D005260:Female; D006801:Humans; D006973:Hypertension / Q000209:etiology; D007022:Hypotension / Q000209:etiology; D007431:Intraoperative Complications / Q000209:etiology; D008297:Male; D016343:Monitoring, Intraoperative / Q000379:methods*; D011183:Postoperative Complications; D011446:Prospective Studies; D012307:Risk Factors; D020521:Stroke / Q000209:etiology; D013997:Time Factors
Carotid surgery; clamping ischemia; general anesthesia; intraoperative cerebral monitoring; intraoperative shunt; perioperative stroke