Document Detail

Angiographic criteria reliably predict when carotid endarterectomy can be safely performed without a shunt.
MedLine Citation:
PMID:  10401745     Owner:  NLM     Status:  MEDLINE    
BACKGROUND: Selective shunting during carotid endarterectomy is widely performed, but the optimal approach for predicting when a shunt is unnecessary remains uncertain. We evaluated the ability of preoperative cerebral angiography to predict when carotid endarterectomy could be safely performed without a shunt. STUDY DESIGN: Eighty-seven patients undergoing carotid endarterectomy between August 1991 and December 1997 had preoperative cerebral angiograms. The angiograms were evaluated for the presence of collateral flow from the contralateral carotid through the anterior communicating artery and from the posterior circulation through the posterior communicating artery. Patients then underwent endarterectomy and were selectively shunted based on somatosensory evoked potential changes. Internal carotid artery stump pressure was routinely measured in all patients. RESULTS: Nine patients (10%) had a shunt placed based on somatosensory evoked potential changes and none of the 87 patients had a perioperative (30 days) stroke. Angiography revealed that 36 patients (41%) had no cross-filling from the contralateral carotid through the anterior communicating artery. Nine of these patients (25%) required a shunt; none of the 51 patients with adequate cross-filling (p < 0.001) did. Furthermore, 94% of the patients without cross-filling but with a patent ipsilateral posterior communicating artery did not require a shunt using somatosensory evoked potential changes as the standard for shunt insertion. Stump pressure measurements (> or = 25 mmHg) or (> or = 50 mmHg) did not reliably exclude the need for a shunt. Only 2 of 15 patients with contralateral carotid occlusion and 1 of 16 patients with a prior ipsilateral stroke required shunts. CONCLUSIONS: In the presence of cross-filling from the contralateral carotid artery, shunt insertion was uniformly unnecessary. In addition, routine shunting of patients with previous ipsilateral strokes or contralateral carotid occlusion was not always necessary. Stump pressures were less sensitive than angiographic criteria in determining when a shunt was unnecessary. Evaluation of cross-filling from the contralateral carotid artery on preoperative angiography can predict with certainty which patients will not require a shunt.
R A Wain; F J Veith; B A Berkowitz; A D Legatt; M Schwartz; E C Lipsitz; S R Haut; J A Bello
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Publication Detail:
Type:  Journal Article; Research Support, Non-U.S. Gov't; Research Support, U.S. Gov't, P.H.S.    
Journal Detail:
Title:  Journal of the American College of Surgeons     Volume:  189     ISSN:  1072-7515     ISO Abbreviation:  J. Am. Coll. Surg.     Publication Date:  1999 Jul 
Date Detail:
Created Date:  1999-07-21     Completed Date:  1999-07-21     Revised Date:  2007-11-14    
Medline Journal Info:
Nlm Unique ID:  9431305     Medline TA:  J Am Coll Surg     Country:  UNITED STATES    
Other Details:
Languages:  eng     Pagination:  93-100; discussion 100-1     Citation Subset:  AIM; IM    
Montefiore Medical Center and Albert Einstein College of Medicine, New York, NY, USA.
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MeSH Terms
Carotid Artery, External / radiography*,  surgery
Carotid Artery, Internal / radiography*,  surgery
Carotid Stenosis / radiography,  surgery
Cerebral Angiography / statistics & numerical data
Endarterectomy, Carotid / methods*
Middle Aged
Reproducibility of Results
Grant Support

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