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