Unplanned Shunting Is Associated with Higher Stroke Risk after Eversion Carotid Endarterectomy


      Shunting during eversion carotid endarterectomy (eCEA) may be technically challenging. Whether shunting practice patterns modify perioperative stroke risk after eCEA is unclear. We aimed to compare eCEA outcomes based on shunting practice.


      The Vascular Quality Initiative (2011–2019) was queried for eCEAs performed for symptomatic and asymptomatic carotid stenosis. Univariable and multivariable analyses compared outcomes based on whether shunting was routine practice, preoperatively-indicated, intraoperatively-indicated, or not performed.


      There were 13,207 eCEAs identified. Average age was 71.4 years and 59.4% of patients were male sex. Ipsilateral carotid stenosis was >80% in 45.6% and there was severe contralateral carotid stenosis in 8.6%. Early ipsilateral symptoms within 14 days of eCEA were transient ischemic attack in 5.6% and stroke in 7%. The majority of cases were performed under general anesthesia (82.7%). Electroencephalogram monitoring and stump pressures were utilized in 30.9% and 14.7%, respectively. Shunting was routine (25.4%), preoperatively-indicated (1.9%), intraoperatively-indicated (4.7%), or not implemented (68%). Preoperatively-indicated shunting was more often performed in patients with early symptomatic carotid stenosis or severe contralateral carotid stenosis. After routine shunting, preoperatively-indicated shunting, intraoperatively-indicated shunting, and no shunting, median operative duration was 110, 101, 112, and 97 min, respectively (P < 0.001), and ipsilateral perioperative stroke prevalence was 0.6%, 1.2%, 1.9%, and 0.7%, respectively (P = 0.004). On multivariable analysis, longer operative time was associated with routine shunting (MR 1.17, 95% CI 1.15–1.19, P < 0.001), preoperatively-indicated shunting (MR 1.09, 95% CI 1.04–1.15, P < 0.001), and intraoperatively-indicated shunting (MR 1.12, 95% CI 1.09–1.16, P < 0.001) compared with no shunting. Compared with no shunting, routine shunting (OR 0.91, 95% CI 0.54–1.54, P = 0.74) and preoperatively-indicated shunting (OR 1.53, 95% CI 0.47–4.99, P = 0.48) were not associated with stroke; however, intraoperatively-indicated shunting was associated with increased stroke (OR 2.74, 95% CI 1.41–5.3, P = 0.003). Shunting type was not associated with perioperative mortality.


      Intraoperatively-indicated shunting during eCEA was associated with longest operative duration and increased perioperative stroke risk. Surgeon familiarity with shunting and planning to shunt in advance may permit more expeditious shunting and prevent stroke.
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        • Bennett K.M.
        • Scarborough J.E.
        • Cox M.W.
        • et al.
        The impact of intraoperative shunting on early neurologic outcomes after carotid endarterectomy.
        J Vasc Surg. 2015; 61: 96-102
        • Hans S.S.
        • Catanescu I.
        Selective shunting for carotid endarterectomy in patients with recent stroke.
        J Vasc Surg. 2015; 61: 915-919
        • Chongruksut W.
        • Vaniyapong T.
        • Rerkasem K.
        Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting).
        Cochrane Database Syst Rev. 2014; 2014: CD000190
        • AbuRahma A.F.
        • Stone P.A.
        • Hass S.M.
        • et al.
        Prospective randomized trial of routine versus selective shunting in carotid endarterectomy based on stump pressure.
        J Vasc Surg. 2010; 51: 1133-1138
        • Levin S.R.
        • Farber A.
        • Goodney P.P.
        • et al.
        Shunt intention during carotid endarterectomy in the early symptomatic period and perioperative stroke risk.
        J Vasc Surg. 2020; 72: 1385-1394.e2
        • Squizzato F.
        • Siracuse J.J.
        • Shuja F.
        • et al.
        Impact of shunting practice patterns during carotid endarterectomy for symptomatic carotid stenosis.
        Stroke. 2022; 53: 2230-2240
        • Ricotta J.J.
        • AbuRahma A.
        • Ascher E.
        • et al.
        Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease.
        J Vasc Surg. 2011; 54: e1-e31
        • Chang B.B.
        • Darling R.C.
        • Patel M.
        • et al.
        Use of shunts with eversion carotid endarterectomy.
        J Vasc Surg. 2000; 32: 655-662
        • Ballotta E.
        • Da Giau G.
        Selective shunting with eversion carotid endarterectomy.
        J Vasc Surg. 2003; 38: 1045-1050
        • Schneider J.R.
        • Helenowski I.B.
        • Jackson C.R.
        • et al.
        A comparison of results with eversion versus conventional carotid endarterectomy from the vascular quality initiative and the Mid-America vascular study group.
        J Vasc Surg. 2015; 61: 1216-1222
        • Berguer R.
        Eversion endarterectomy of the carotid bifurcation.
        Curr Crit Probl Vasc Surg. 1993; 5: 441-447
        • Koskas F.
        • Kieffer E.
        • Bahnini A.
        • et al.
        Carotid eversion endarterectomy: short- and long-term results.
        Ann Vasc Surg. 1995; 9: 9-15
        • Reigner B.
        • Reveilleau P.
        • Gayral M.
        • et al.
        Eversion endarterectomy of the internal carotid artery: midterm results of a new technique.
        Ann Vasc Surg. 1995; 9: 241-246
        • Bensley R.P.
        • Beck A.W.
        Using the Vascular Quality Initiative to improve quality of care and patient outcomes for vascular surgery patients.
        Semin Vasc Surg. 2015; 28: 97-102
        • Levin S.R.
        • Farber A.
        • Cheng T.W.
        • et al.
        Most patients experiencing 30-day postoperative stroke after carotid endarterectomy will initially experience disability.
        J Vasc Surg. 2019; 70: 1499-1505.e1
        • Dakour-Aridi H.
        • Ou M.
        • Locham S.
        • et al.
        Outcomes following eversion versus conventional endarterectomy in the vascular quality initiative database.
        Ann Vasc Surg. 2020; 65: 1-9
        • Davidovic L.B.
        • Tomic I.Z.
        Eversion carotid endarterectomy: a short review.
        J Korean Neurosurg Soc. 2020; 63: 373-379