Highlights
- •There is a continuing debate regarding the indications for an intraoperative shunt while performing carotid endarterectomy (CEA). Previous studies have determined these indications based on changes in monitored parameters after cross-clamping reflecting cerebral ischemia. The purpose of our study was to evaluate arterial blood flow (ABF) directly on the carotid artery (direct-ABF) as a potential predictor of cerebral ischemia prior to cross-clamping. The ABF ratio (ABF-internal carotid artery/ABF-common carotid artery) can be a useful predictor of ischemia before cross-clamping.
Abstract
Background
Cross-clamping during carotid endarterectomy (CEA) is associated with the risk of
cerebral ischemia. Various studies have evaluated different criteria for detecting
cerebral ischemia, but difficulties arise when ischemic changes appear after the carotid
artery is cross-clamped and incised. Here, we explored a parameter that can predict
cerebral ischemia prior to cross-clamping during CEA using a blood-flow meter.
Methods
The carotid arterial blood flow was measured directly (direct ABF) in the common carotid
artery prior to cross-clamping. The anatomical information in preoperative magnetic
resonance imaging, cerebral blood flow in xenon-enhanced computed tomography, and
carotid peak systolic flow velocity by carotid echo from the skin surface were also
evaluated. A decrease in the short-latency somatosensory evoked potentials (SSEP)
during cross-clamping to insert a shunt was assessed, and a decrease in amplitude
of ≥ 50% was considered an indicator for cerebral ischemia. Surgery was performed
under general anesthesia, and a shunt was inserted in all cases.
Results
Of 156 CEA patients between April 2013 and March 2020, 30 had decreased SSEP during
cross-clamping. The baseline characteristics and intra- and postoperative findings
were not significantly different between patients with and without a decrease in SSEP.
Among the evaluated parameters, only the direct-ABF ratio (ABF-internal carotid artery/ABF-common
carotid artery) differed significantly between the 2 groups (P = 0.011). The direct-ABF ratio ≤ 0.58 was predictive of cerebral ischemia during
CEA.
Conclusions
Direct-ABF measurement with an ultrasonic blood-flow meter can be useful for predicting
cerebral ischemia prior to carotid artery cross-clamping during CEA.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Annals of Vascular SurgeryAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
REFERENCES
- Relationship between circle of Willis morphology on 3D time-of-flight MR angiograms and transient ischemia during vascular clamping of the internal carotid artery during carotid endarterectomy.Am J Neuroradiol. 2004; 25: 558-564
- Preopeative MRA flow quantifiation in CEA patients:flow differences between patients who develop cerebral ischemia and patients who do not develop cerebral ischemia during cross-clamping of the cartoid artery.Stroke. 2000; 31: 3021-3028
- Near infrared spectroscopy as a predictor for shunt requirement during carotid endarterectomy.Eur J Vasc Endovasc Surg. 2017; 53: 783-791
- Diagnostic value of somatosensory evoked potential changes during carotid endarterectomy: A systematic review and meta-analysis.JAMA Neurol. 2015; 72: 73-80
- Predictors of cross-clamp-induced intraoperative monitoring changes during carotid endarterectomy using both electroencephalography and somatosensory evoked potentials.J Vasc Surg. 2018; 67: 191-198
- Usefulness of ultrasonologic examinations on microemboli and hemodynamics for the prevention of complications associated with carotid endarterectomy.J Stroke Cerebrovasc Dis. 2003; 12: 51-58
- Intraoperative cerebral monitoring during carotid surgery: a narrative review.Ann Vasc Surg. 2021; : 1-9
- Pre-operative methods to predict need for shunting during carotid endarterectomy.Int J Surg. 2015; 23: 5-11
- Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis.N Engl J Med. 1991; 325: 445-453
- Cerebral ischemia during carotid artery cross-clamping : Predictive value of phase-contrast magnetic resonance imaging.Ann Vasc Surg. 2006; 20: 747-752
- Somatosensory evoked potential monitoring in carotid surgery. I. Relationships between qualitative SEP alterations and intraoperative events.Electroencephalogr Clin Neurophysiol. 1997; 104: 459-469
- Somatosensory-evoked potentials during carotid artery surgery: Experience in 400 operations.Surgery. 1991; 109: 602-609
- Somatosensory evoked potential monitoring during carotid surgery.Cardiovasc Surg. 1996; 4: 77-80
- Comparison of near-infrared spectroscopy and somatosensory evoked potentials for the detection of cerebral ischemia during carotid endarterectomy.Stroke. 1998; 29: 2032-2037
- Stump pressure and somatosensory evoked potentials for predicting the use of shunt during carotid surgery.Ann Vasc Surg. 2007; 21: 312-317
- The role of carotid stump pressure in carotid endarterectomy: A systematic review and meta-analysis.Ann Vasc Dis. 2020; 13: 28-37
- Comparing the efficacy of shunting approaches and cerebral monitoring during carotid endarterectomy using a national database.J Vasc Surg. 2018; 68: 416-425
- Predictors of shunt during carotid endarterectomy with routine electroencephalography monitoring.J Vasc Surg. 2009; 49: 1374-1378
- Improvement of carotid blood flow after carotid endarterectomy—evaluation using intraoperative ultrasound flow measurement.Eur J Vasc Endovasc Surg. 2003; 25: 168-174
- Risk index for predicting shunt in carotid endarterectomy.Ann Vasc Surg. 2014; 28: 1204-1212
- Cerebral oximetry does not correlate with electroencephalography and somatosensory evoked potentials in determining the need for shunting during carotid endarterectomy.J Vasc Surg. 2008; 48: 601-606
- Incompleteness of the circle of Willis is related to EEG-based shunting during carotid endarterectomy.Eur J Vasc Endovasc Surg. 2013; 46: 631-637
- Perioperative and long-term outcomes of carotid endarterectomy for Japanese asymptomatic cervical carotid artery stenosis: A single institution study.Neurol Med Chir (Tokyo). 2015; 55: 830-837
Article Info
Publication History
Published online: December 22, 2021
Accepted:
November 29,
2021
Received in revised form:
November 18,
2021
Received:
September 8,
2021
Identification
Copyright
© 2021 Elsevier Inc. All rights reserved.
