title: Outcome Analysis of Carotid Cross-Clamp Intolerance during Carotid Endarterectomy under Locoregional Anesthesia.
abstract: BACKGROUND
  To analyze the predictors and describe the outcomes of cross-clamp intolerance (CCI) and the results of the use of carotid endarterectomy (CEA) with shunting or a shift strategy to immediate carotid artery stenting (CAS) in this setting.
  
  
  METHODS
  Between January 2008 and December 2015, 385 patients were elected for single-sided, isolated CEA under locoregional anesthesia. In case of CCI, CEA with shunt was used selectively, whereas indication to immediate conversion to CAS was the immediate onset and severe persistent deterioration of the neurologic status, and/or local technical difficulties to perform endarterectomy. Primary outcome was prevention of death and all early (<30 days) perioperative cerebrovascular events.
  
  
  RESULTS
  We treated 169 (43.9%) symptomatic lesions; urgent (≤48 hours) intervention was performed in 85 (22.1%) cases. Carotid CCI occurred in 45 (11.7%) patients. CEA with shunt was used in 16, whereas CAS in 27 (7.0%, 2 refused further treatment). Multivariable analysis identified hypertension (odds ratio [OR]: 2.93, 95% confidence interval [CI]: 1.01-8.52; P = 0.049) and symptomatic lesions (OR: 2.34, 95% CI: 1.11-4.93; P = 0.025) as significant predictors of CCI. In-hospital mortality rate was 0.5%; none occurred in CCI group. Postoperative cerebrovascular event rate was 2.3% (n = 9). At multivariable analyses, only CCI (OR: 6.60, 95% CI: 1.65-26.36; P = 0.008) was significantly associated with postoperative cerebrovascular events, with no significant different clinical outcomes between CEA and CAS.
  
  
  CONCLUSIONS
  Hypertension and symptomatic carotid stenosis were significant predictors of CCI, which was found to be predictive for postoperative cerebrovascular events. In selected patients with CCI, CAS had satisfactory, similar results of CEA.
authors.affiliation: Division of Vascular Surgery, Department of Surgery and Morphological Sciences, University of Insubria School of Medicine, Circolo University Hospital, Varese, Italy. Electronic address: gabriele.piffaretti@uninsubria.it.
authors.forename: Gabriele
authors.initials: G
authors.lastname: Piffaretti
authors.affiliation: Division of Vascular Surgery, Department of Surgery and Morphological Sciences, University of Insubria School of Medicine, Circolo University Hospital, Varese, Italy.
authors.forename: Antonino
authors.initials: A
authors.lastname: Tarallo
authors.affiliation: Division of Vascular Surgery, Department of Surgery and Morphological Sciences, University of Insubria School of Medicine, Circolo University Hospital, Varese, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Franchin
authors.affiliation: Department of Anesthesia and Palliative Care, Circolo University Hospital, Varese, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Bacuzzi
authors.affiliation: Division of Vascular Surgery, Department of Surgery and Morphological Sciences, University of Insubria School of Medicine, Circolo University Hospital, Varese, Italy.
authors.forename: Nicola
authors.initials: N
authors.lastname: Rivolta
authors.affiliation: Division of Vascular Surgery, Department of Surgery and Morphological Sciences, University of Insubria School of Medicine, Circolo University Hospital, Varese, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Ferrario
authors.affiliation: Division of Vascular Surgery, Department of Surgery and Morphological Sciences, University of Insubria School of Medicine, Circolo University Hospital, Varese, Italy.
authors.forename: Stefania
authors.initials: S
authors.lastname: Ferraro
authors.affiliation: Division of Vascular Surgery, Department of Surgery and Morphological Sciences, University of Insubria School of Medicine, Circolo University Hospital, Varese, Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Bossi
authors.affiliation: Division of Vascular Surgery, Department of Surgery and Morphological Sciences, University of Insubria School of Medicine, Circolo University Hospital, Varese, Italy.
authors.forename: Patrizio
authors.initials: P
authors.lastname: Castelli
authors.affiliation: Division of Vascular Surgery, Department of Surgery and Morphological Sciences, University of Insubria School of Medicine, Circolo University Hospital, Varese, Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Tozzi
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000765:Anesthesia, Conduction / Q000009:adverse effects / Q000401:mortality; D016893:Carotid Stenosis / Q000150:complications / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D002560:Cerebrovascular Circulation; D002561:Cerebrovascular Disorders / Q000209:etiology / Q000503:physiopathology; D016009:Chi-Square Distribution; D003250:Constriction; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome