Prospective randomized trial of routine versus selective shunting in carotid endarterectomy based on stump pressure.

Abstract

BACKGROUND:

The use of shunting in carotid endarterectomy (CEA) is controversial. This randomized trial compared the results of routine (RS) vs selective shunting (SS) based on stump pressure (SP).

METHODS:

Two-hundred CEA patients under general anesthesia were randomized into RS (98 patients) or SS (102 patients), where shunting was used only if systolic SP (SSP) was <40 mm Hg. Clinical and demographic characteristics were comparable in both groups. Patients underwent immediate and 30-day postoperative duplex ultrasound follow-up. Analysis was by intention-to-treat.

RESULTS:

Of 102 SS patients, 29 (28%) received shunting. Indications for CEA were similar (42% symptomatic for RS; 47% for SS, P = .458). The mean internal carotid artery diameter was comparable (5.5 vs 5.5 mm, P = .685). Mean preoperative ipsilateral and contralateral stenosis was 76% and 38% for RS (P = .268) vs 78% and 40% for SS (P = .528). Mean preoperative ipsilateral and contralateral stenosis was 79% and 56% in the shunted (P = .634) vs 78% and 34% in the nonshunted subgroup of SS patients (P = .002). The mean SSP was 55.9 mm Hg in RS vs 56.2 for SS (P = .915). The mean SSP was 33 mm Hg in the shunted vs 65 in the nonshunted subgroup (P < .0001). Mean clamp time in the nonshunted subgroup of SS was 32 minutes. Mean shunt time was 35 minutes in RS and 33 in SS (P = .354). Mean operative time was 113 minutes for RS and 109 for SS (P = .252), and 111 minutes in shunted and 108 in the nonshunted subgroup (P = .586). Mean arteriotomy length was 4.4 cm for RS and 4.2 for SS (P = .213). Perioperative stroke rate was 0% for RS vs 2% for SS (one major and one minor stroke, both related to carotid thrombosis; P = .498). No patients died perioperatively. Combined perioperative transient ischemic attack (TIA) and stroke rates were 2% in RS vs 2.9% in SS (P > .99). The overall perioperative complication rates were 8.3% in RS (2 TIA, 3 hemorrhage, 1 myocardial infarction [MI], and 1 asymptomatic carotid thrombosis) vs 7.8% in SS (2 strokes, 1 TIA, 3 hemorrhage, 1 MI, and 1 congestive heart failure; P = .917).

CONCLUSIONS:

RS and SS were associated with a low stroke rate. Both methods are acceptable, and surgeons should select the method with which they are more comfortable.

• Authors: Ali F Aburahma, Patrick A Stone, Stephen M Hass, L Scott Dean, Joseph Habib, Tammi Keiffer, Mary Emmett
• Journal: Journal of vascular surgery (J Vasc Surg) Vol. 51 Issue 5 Pg. 1133-8 (May 2010) ISSN: 1097-6809 [Electronic] United States
• PMID: 20347544 (Publication Type: Comparative Study, Journal Article, Randomized Controlled Trial)
• Copyright: Copyright (c) 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Topics

• Aged
• Aged, 80 and over
• Brain Ischemia (prevention & control)
• Carotid Stenosis (diagnostic imaging, mortality, physiopathology, surgery)
• Cerebrovascular Circulation (physiology)
• Combined Modality Therapy
• Endarterectomy, Carotid (methods)
• Female
• Follow-Up Studies
• Humans
• Intraoperative Complications (prevention & control)
• Male
• Middle Aged
• Patient Selection
• Pressure
• Prospective Studies
• Risk Assessment
• Treatment Outcome
• Ultrasonography, Doppler, Duplex