Download PDF
Int J Angiol 2012; 21(03): 135-138
DOI: 10.1055/s-0032-1324734
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Carotid Endarterectomy with Contralateral Carotid Occlusion: Is Shunting Necessary?

Austin Ward
1   Department of Surgery, University of Kentucky, Lexington, Kentucky
,
Victor Ferraris
2   Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
,
Sibu Saha
2   Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
› Author Affiliations
Further Information

Publication History

Publication Date:
22 August 2012 (online)

    Permissions and Reprints

Abstract

Background Controversy exists about the effect of contralateral carotid stenosis on the perioperative risks of carotid endarterectomy (CEA). Despite increased perioperative risk, the long-term outcome is improved in patients who undergo ipsilateral CEA with significant contralateral carotid stenosis. Traditionally, this involved shunting the ipsilateral carotid artery during the procedure. It was believed that this minimized the risk for cerebral ischemia. We believe selective shunting can be employed while still avoiding cerebral ischemia. This requires a reliable method of monitoring for ischemia. Intraoperative EEG monitoring has been proven to be a reliable method for monitoring for ischemic changes during a case.

Methods A standard operative technique involving continuous EEG monitoring was used. We reviewed the records of carotid endarterectomies in the past 3 years. We present a series of 8 cases of CEA with contralateral occlusion in which shunting was selective based on EEG.

Results Of eight patients, seven (87.5%) tolerated the procedure without EEG changes and thus did not requiring intraluminal shunting. There were no long-term complications in our series of patients.

Conclusion We found that intraluminal carotid shunting during CEA with contralateral occlusion is not mandatory but neuroprotection methods need to be added to the operative procedure to ensure safety.

Keywords

carotid endarterectomy - cerebral protection - contralateral occlusion - carotid shunting
 

  • References

  • 1 Mukherjee D, Yadav JS. Effect of contralateral occlusion on long-term efficacy of endarterectomy in the Asymptomatic Carotid Atherosclerosis Study (ACAS). Stroke 2001; 32 (6) 1443-1448
    PubMedGoogle Scholar
  • 2 Baker WH, Howard VJ, Howard G, Toole JF ; ACAS Investigators. Effect of contralateral occlusion on long-term efficacy of endarterectomy in the Asymptomatic Carotid Atherosclerosis Study (ACAS). Stroke 2000; 31 (10) 2330-2334
    CrossrefPubMedGoogle Scholar
  • 3 Ferguson GG, Eliasziw M, Barr HW , et al. The North American Symptomatic Carotid Endarterectomy Trial: surgical results in 1415 patients. Stroke 1999; 30 (9) 1751-1758
    CrossrefPubMedGoogle Scholar
  • 4 AbuRahma AF, Metz MJ, Robinson PA. Natural history of > or = 60% asymptomatic carotid stenosis in patients with contralateral carotid occlusion. Ann Surg 2003; 238 (4) 551-561 , discussion 561–562
    PubMedGoogle Scholar
  • 5 Naylor AR, Rothwell PM, Bell PR. Overview of the principal results and secondary analyses from the European and North American randomised trials of endarterectomy for symptomatic carotid stenosis. Eur J Vasc Endovasc Surg 2003; 26 (2) 115-129
    CrossrefPubMedGoogle Scholar
  • 6 Barnett HJ, Meldrum HE, Eliasziw M ; North American Symptomatic Carotid Endarterectomy Trial (NASCET) collaborators. The appropriate use of carotid endarterectomy. CMAJ 2002; 166 (9) 1169-1179
    PubMedGoogle Scholar
  • 7 Anthony T, Johansen K. Optimal outcome for “high-risk” carotid endarterectomy. Am J Surg 1994; 167 (5) 469-471
    CrossrefPubMedGoogle Scholar
  • 8 Coyle KA, Smith III RB, Salam AA, Dodson TF, Chaikof EL, Lumsden AB. Carotid endarterectomy in patients with contralateral carotid occlusion: review of a 10-year experience. Cardiovasc Surg 1996; 4 (1) 71-75
    CrossrefPubMedGoogle Scholar
  • 9 Bond R, Rerkasem K, Counsell C , et al. Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting). Cochrane Database Syst Rev 2002; 2 (2) CD000190
    PubMedGoogle Scholar
  • 10 Ferguson GG. Carotid endarterectomy. To shunt or not to shunt?. Arch Neurol 1986; 43 (6) 615-617
    CrossrefPubMedGoogle Scholar
  • 11 Inoue T, Tsutsumi K, Maeda K , et al. Incidence of ischemic lesions by diffusion-weighted imaging after carotid endarterectomy with routine shunt usage. Neurol Med Chir (Tokyo) 2006; 46 (11) 529-533 , discussion 534
    CrossrefPubMedGoogle Scholar
  • 12 Eidt JF, Kahn MB, Barone GW, Cook JM, Barnes RW. Malfunction of a double-balloon carotid shunt as a result of herniation of the proximal balloon. J Vasc Surg 1990; 12 (1) 62-64
    PubMedGoogle Scholar
  • 13 Schneider JR, Droste JS, Schindler N, Golan JF, Bernstein LP, Rosenberg RS. Carotid endarterectomy with routine electroencephalography and selective shunting: Influence of contralateral internal carotid artery occlusion and utility in prevention of perioperative strokes. J Vasc Surg 2002; 35 (6) 1114-1122
    CrossrefPubMedGoogle Scholar
  • 14 Browse NL, Ross-Russell R. Carotid endarterectomy and the Javid shunt: the early results of 215 consecutive operations for transient ischaemic attacks. Br J Surg 1984; 71 (1) 53-57
    CrossrefPubMedGoogle Scholar