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Hejčl A, Jiránková K, Malucelli A, Sejkorová A, Radovnický T, Bartoš R, Orlický M, Brušáková Š, Hrach K, Kastnerová J, Sameš M. Selective internal carotid artery cross-clamping increases the specificity of cerebral oximetry for indication of shunting during carotid endarterectomy. Acta Neurochir (Wien) 2021; 163:1807-1817. [PMID: 33106902 DOI: 10.1007/s00701-020-04621-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/12/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND An indication for selective shunting during carotid endarterectomy (CEA) is based on monitoring during a procedure. Cerebral oximetry (CO) using near-infrared spectroscopy (NIRS) may be a simple technique, but its relevance during CEA, especially with respect to cutoff values indicating shunt implantation, still needs to be elucidated. METHODS One hundred twenty five patients underwent CEA under local anesthesia (LA) and were monitored clinically throughout the whole procedure. The patients were also monitored using bilateral NIRS probes during surgery. The NIRS values were recorded and evaluated before and after selective cross-clamping, firstly by the external carotid artery (ECA), followed by the internal carotid artery (ICA). The decrease in the ipsilateral CO values, with respect to the indication of shunting, was only analyzed after selective cross-clamping of the ICA. The decision to use an intraluminal shunt was solely based on the neurological status evaluation after ICA cross-clamping. RESULTS One hundred five patients (85%) were stable throughout the CEA, while 20 patients (15%) clinically deteriorated during surgery. The mean drop in the CO after selective ICA clamping in clinically stable patients was 6%, while in patients with clinical deterioration, the NIRS decreased by 14.5% (p < 0.05). When the cutoff value for selective shunting was set as a 10% decrease of the ipsilateral CO after selective ICA clamping, the sensitivity of the technique was 100% and the specificity 83.0%. CONCLUSIONS Our study showed that a 10% decrease in the ipsilateral brain tissue oximetry after selective cross-clamping the ICA provides a reliable cutoff value for selective shunting during CEA. Despite the availability of a variety of monitoring tools, the NIRS may be an easy, reliable option, especially in the scenario of acute CEA in general anesthesia.
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Affiliation(s)
- A Hejčl
- Neurosurgery Department, Masaryk Hospital, J. E. Purkyně University, Sociální péče 12A, 401 13, Ústí nad Labem, Czech Republic.
- International Clinical Research Center, St. Anne's Hospital, Brno, Czech Republic.
- Institute of Experimental Medicine, Academy of Sciences of the Czech Republic, Prague, Czech Republic.
| | - K Jiránková
- 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
| | - A Malucelli
- Neurosurgery Department, Masaryk Hospital, J. E. Purkyně University, Sociální péče 12A, 401 13, Ústí nad Labem, Czech Republic
| | - A Sejkorová
- Neurosurgery Department, Masaryk Hospital, J. E. Purkyně University, Sociální péče 12A, 401 13, Ústí nad Labem, Czech Republic
| | - T Radovnický
- Neurosurgery Department, Masaryk Hospital, J. E. Purkyně University, Sociální péče 12A, 401 13, Ústí nad Labem, Czech Republic
| | - R Bartoš
- Neurosurgery Department, Masaryk Hospital, J. E. Purkyně University, Sociální péče 12A, 401 13, Ústí nad Labem, Czech Republic
| | - M Orlický
- Neurosurgery Department, Masaryk Hospital, J. E. Purkyně University, Sociální péče 12A, 401 13, Ústí nad Labem, Czech Republic
| | - Š Brušáková
- Department of Neurology, Masaryk Hospital, Ústí nad Labem, Czech Republic
| | - K Hrach
- Faculty of Health Studies, J. E. Purkyne University, Ústí nad Labem, Czech Republic
| | - J Kastnerová
- Department of Anesthesiology, Intensive Care and Perioperative Medicine, Masaryk Hospital, J. E. Purkyne University, Ústí nad Labem, Czech Republic
| | - M Sameš
- Neurosurgery Department, Masaryk Hospital, J. E. Purkyně University, Sociální péče 12A, 401 13, Ústí nad Labem, Czech Republic
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Kawamura Y, Maruyama D, Akagi Y, Iihara K. Effective Intraluminal Shunt in Carotid Endarterectomy for Carotid Artery Near Occlusion: Technical Report. World Neurosurg 2017; 106:813-818. [PMID: 28739521 DOI: 10.1016/j.wneu.2017.07.078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 07/13/2017] [Accepted: 07/14/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Carotid artery near occlusion is a critical degree of stenosis whereby blood flow is decreased and the distal cervical and intracranial internal carotid arteries (ICAs) are prone to collapse. Considering the diminished perfusion and risk of progression to total occlusion and periocclusive embolism, we performed carotid endarterectomy for carotid artery near occlusion. METHODS Accurate evaluation of tandem stenosis or patency of the poststenotic ICA in carotid artery near occlusion is often difficult preoperatively. Thus we performed carotid endarterectomy in a hybrid operating room where intraoperative digital subtraction angiography (DSA) and endovascular angioplasty or stenting for distal lesions can be performed if necessary. In addition, to evaluate the distal ICA intraoperatively, we used an intraluminal shunt for shunt angiography, with injection of contrast material through the shunt tube, as a replacement for conventional DSA. Furthermore, an intraluminal shunt held the collapsed lumen open and provided a scaffold for suturing, which prevented postoperative stenosis of the distal ICA. CONCLUSION The present report is intended to underline the merits of intraluminal shunt as a replacement for conventional DSA and as a scaffold for suturing.
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Affiliation(s)
- Yoichiro Kawamura
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan.
| | - Daisuke Maruyama
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yojiro Akagi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
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Hitotsumatsu T, Nishimura A, Ido K, Ishido K, Ito O. Triple-balloon shunt placement for carotid endarterectomy: a novel intraluminal shunt designed to preserve the internal and external carotid blood flow. World Neurosurg 2014; 82:239.e5-8. [PMID: 24549016 DOI: 10.1016/j.wneu.2014.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Revised: 10/08/2013] [Accepted: 01/29/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To report a newly developed intraluminal triple-balloon shunt designed to preserve the blood flow of both the internal carotid artery (ICA) and the external carotid artery (ECA) during carotid endarterectomy in patients with a previous ipsilateral extracranial-intracranial bypass, in whom hemodynamic cerebral ischemia might be caused by cross-clamping at the ICA as well as the ECA. METHODS The novel device consists of 3 silicone tubes equipped with balloons at each end. The design facilitates insertion proximally to the common carotid artery and distally to both the ICA and the ECA. RESULTS The new shunt tube was used in 3 patients, each of whom had previously undergone ipsilateral superficial temporal artery-middle cerebral artery bypass for proximal middle cerebral artery occlusion. The blood flow of the middle cerebral artery and anterior cerebral artery was supplied independently from the ECA via the bypass and from the ICA, respectively. There were no shunt-related complications. CONCLUSIONS This novel shunt device can be used safely and effectively in cases requiring preservation of the blood supply to both the ICA and the ECA during carotid endarterectomy.
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Abstract
Temporary vascular shunts have been used for nearly 100 years in patients. Originally, they were used as vascular grafts that were likely to thrombose as collaterals would hopefully develop. More recently, they have been used as a device to be replaced by a permanent vascular graft during the same operation or at a reoperation. Indications for the use of shunts are a "damage control" procedure for a peripheral or truncal vascular injury, Gustilo IIIC fracture of an extremity, need for perfusion as a complex revascularization is performed, and planned replantation of a hand, forearm, or arm. They are used in approximately 8% of vascular injuries treated in urban trauma centers in the United States and have an excellent patency rate without heparinization.
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Affiliation(s)
- D V Feliciano
- Atlanta Medical Center, Atlanta, GA, USA.
- Mercer University School of Medicine, Macon, GA, USA.
- , 1244 Village Run, NE, Atlanta, GA, 30319, USA.
| | - A Subramanian
- Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
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