Skip to main content
NCBI home page
Annals of Surgery logoLink to Annals of Surgery
. 1986 Feb;203(2):196–204. doi: 10.1097/00000658-198602000-00014

The risk-benefit ratio of intraoperative shunting during carotid endarterectomy. Relevancy to operative and postoperative results and complications.

T M Sundt Jr, M J Ebersold, F W Sharbrough, D G Piepgras, W R Marsh, J M Messick Jr
PMCID: PMC1251069  PMID: 3947156

Abstract

The relative risk of shunting versus not shunting during carotid endarterectomy was analyzed retrospectively in 1935 cases undergoing carotid endarterectomy for carotid ulcerative stenosis. The need for shunting was based on a correlation between electroencephalographic changes and a fall in cerebral blood flow below the critical level required for adequate perfusion during the period of carotid occlusion. Patients were divided into four risk categories for surgery, based on medical and neurological risks and angiographic findings. Shunts were required in 30% of the low risk group and 56% of the high risk group. Based on the severity of reductions of cerebral blood flow during the period of carotid occlusion it is concluded that 12% of all patients would have sustained a major deficit, 15% a minor or transient deficit, and 20% a transient deficit without shunting. The risk of shunting 792 cases in this series was 0.5%. Overall minor morbidity, major morbidity, and mortality each approximated 1% in this series.

Full text

PDF
196

Images in this article

198FIGS. 1A-C.
on p.198
198FIGS. 1D and E.
on p.198
198FIGS. 1F and G.
on p.198
198FIG. 2.
on p.198

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Allen G. S., Preziosi T. J. Carotid endarterectomy: a prospective study of its efficacy and safety. Medicine (Baltimore) 1981 Jul;60(4):298–309. [PubMed] [Google Scholar]
  2. Anderson R. E., Sundt T. M., Jr An automated cerebral blood flow analyzer: concise communication. J Nucl Med. 1977 Jul;18(7):728–731. [PubMed] [Google Scholar]
  3. Baker W. H., Dorner D. B., Barnes R. W. Carotid endarterectomy: is an indwelling shunt necessary? Surgery. 1977 Sep;82(3):321–326. [PubMed] [Google Scholar]
  4. Bland J. E., Lazar M. L. Carotid endarterectomy without shunt. Neurosurgery. 1981 Feb;8(2):153–157. doi: 10.1227/00006123-198102000-00003. [DOI] [PubMed] [Google Scholar]
  5. Bloodwell R. D., Hallman G. L., Keats A. S., Cooley D. A. Carotid endarterectomy without a shunt. Results using hypercarbic general anesthesia to prevent cerebral ischemia. Arch Surg. 1968 Apr;96(4):644–652. doi: 10.1001/archsurg.1968.01330220160025. [DOI] [PubMed] [Google Scholar]
  6. Boysen G., Engell H. C., Henriksen H. The effect of induced hypertension on internal carotid artery pressure and regional cerebral blood flow during temporary carotid clamping for endarterectomy. Neurology. 1972 Nov;22(11):1133–1144. doi: 10.1212/wnl.22.11.1133. [DOI] [PubMed] [Google Scholar]
  7. Branston N. M., Strong A. J., Symon L. Extracellular potassium activity, evoked potential and tissue blood flow. Relationships during progressive ischaemia in baboon cerebral cortex. J Neurol Sci. 1977 Jul;32(3):305–321. doi: 10.1016/0022-510x(77)90014-4. [DOI] [PubMed] [Google Scholar]
  8. Crowell R. M., Olsson Y., Klatzo I., Ommaya A. Temporary occlusion of the middle cerebral artery in the monkey: clinical and pathological observations. Stroke. 1970 Nov-Dec;1(6):439–448. doi: 10.1161/01.str.1.6.439. [DOI] [PubMed] [Google Scholar]
  9. Easton J. D., Sherman D. G. Stroke and mortality rate in carotid endarterectomy: 228 consecutive operations. Stroke. 1977 Sep-Oct;8(5):565–568. doi: 10.1161/01.str.8.5.565. [DOI] [PubMed] [Google Scholar]
  10. Ferguson G. G. Intra-operative monitoring and internal shunts: are they necessary in carotid endarterectomy? Stroke. 1982 May-Jun;13(3):287–289. doi: 10.1161/01.str.13.3.287. [DOI] [PubMed] [Google Scholar]
  11. Giannotta S. L., Dicks R. E., 3rd, Kindt G. W. Carotid endarterectomy: technical improvements. Neurosurgery. 1980 Oct;7(4):309–312. doi: 10.1227/00006123-198010000-00001. [DOI] [PubMed] [Google Scholar]
  12. Goldstone J., Moore W. S. Emergency carotid artery surgery in neurologically unstable patients. Arch Surg. 1976 Nov;111(11):1284–1291. doi: 10.1001/archsurg.1976.01360290118018. [DOI] [PubMed] [Google Scholar]
  13. Green R. M., Messick W. J., Ricotta J. J., Charlton M. H., Satran R., McBride M. M., DeWeese J. A. Benefits, shortcomings, and costs of EEG monitoring. Ann Surg. 1985 Jun;201(6):785–792. doi: 10.1097/00000658-198506000-00017. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Hanson E. J., Anderson R. E., Sund T. M., Jr Comparison of 85krypton and 133xenon cerebral blood flow measurements before, during, and following focal, incomplete ischemia in the squirrel monkey. Circ Res. 1975 Jan;36(1):18–26. doi: 10.1161/01.res.36.1.18. [DOI] [PubMed] [Google Scholar]
  15. Hays R. J., Levinson S. A., Wylie E. J. Intraoperative measurement of carotid back pressure as a guide to operative management for carotid endarterectomy. Surgery. 1972 Dec;72(6):953–960. [PubMed] [Google Scholar]
  16. Hertzer N. R., Beven E. G., Greenstreet R. L., Humphries A. W. Internal carotid back pressure, intraoperative shunting, ulcerated atheromata, and the incidence of stroke during carotid endarterectomy. Surgery. 1978 Mar;83(3):306–312. [PubMed] [Google Scholar]
  17. Hoff J. T., Smith A. L., Hankinson H. L., Nielsen S. L. Barbiturate protection from cerebral infarction in primates. Stroke. 1975 Jan-Feb;6(1):28–33. doi: 10.1161/01.str.6.1.28. [DOI] [PubMed] [Google Scholar]
  18. Humphries A. W., Young J. R., Santilli P. H., Beven E. G., deWolfe V. G. Unoperated, asymptomatic significant internal carotid artery stenosis: a review of 182 instances. Surgery. 1976 Dec;80(6):695–698. [PubMed] [Google Scholar]
  19. Imparato A. M., Ramirez A., Riles T., Mintzer R. Cerebral protection in carotid surgery. Arch Surg. 1982 Aug;117(8):1073–1078. doi: 10.1001/archsurg.1982.01380320057015. [DOI] [PubMed] [Google Scholar]
  20. Javid H., Ostermiller W. E., Hengesh J. W., Dye W. S., Hunter J. A., Najafi H., Julian O. C. Carotid endarterectomy for asymptomatic patients. Arch Surg. 1971 Apr;102(4):389–391. doi: 10.1001/archsurg.1971.01350040151029. [DOI] [PubMed] [Google Scholar]
  21. Javid H., Ostermiller W. E., Jr, Hengesh J. W., Dye W. S., Najafi H., Julian O. C. Natural history of carotid bifurcation atheroma. Surgery. 1970 Jan;67(1):80–86. [PubMed] [Google Scholar]
  22. Jones T. H., Morawetz R. B., Crowell R. M., Marcoux F. W., FitzGibbon S. J., DeGirolami U., Ojemann R. G. Thresholds of focal cerebral ischemia in awake monkeys. J Neurosurg. 1981 Jun;54(6):773–782. doi: 10.3171/jns.1981.54.6.0773. [DOI] [PubMed] [Google Scholar]
  23. Kety S. S., Schmidt C. F. THE NITROUS OXIDE METHOD FOR THE QUANTITATIVE DETERMINATION OF CEREBRAL BLOOD FLOW IN MAN: THEORY, PROCEDURE AND NORMAL VALUES. J Clin Invest. 1948 Jul;27(4):476–483. doi: 10.1172/JCI101994. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Kistler J. P., Ropper A. H., Heros R. C. Therapy of ischemic cerebral vascular disease due to atherothrombosis. (2). N Engl J Med. 1984 Jul 12;311(2):100–105. doi: 10.1056/NEJM198407123110206. [DOI] [PubMed] [Google Scholar]
  25. Lassen N. A. Control of cerebral circulation in health and disease. Circ Res. 1974 Jun;34(6):749–760. doi: 10.1161/01.res.34.6.749. [DOI] [PubMed] [Google Scholar]
  26. Lassen N. A. The luxury-perfusion syndrome and its possible relation to acute metabolic acidosis localised within the brain. Lancet. 1966 Nov 19;2(7473):1113–1115. doi: 10.1016/s0140-6736(66)92199-4. [DOI] [PubMed] [Google Scholar]
  27. Levin S. M., Sondheimer F. K., Levin J. M. The contralateral diseased but asymptomatic carotid artery: to operate or not? An update. Am J Surg. 1980 Aug;140(2):203–205. doi: 10.1016/0002-9610(80)90005-7. [DOI] [PubMed] [Google Scholar]
  28. Matsumoto G. H., Baker J. D., Watson C. W., Gleucklich B., Callow A. D. EEG surveillance as a means of extending operability in high risk carotid endarterectomy. Stroke. 1976 Nov-Dec;7(6):554–559. doi: 10.1161/01.str.7.6.554. [DOI] [PubMed] [Google Scholar]
  29. Michenfelder J. D., Milde J. H., Sundt T. M., Jr Cerebral protection by barbiturate anesthesia. Use after middle cerebral artery occlusion in Java monkeys. Arch Neurol. 1976 May;33(5):345–350. doi: 10.1001/archneur.1976.00500050031006. [DOI] [PubMed] [Google Scholar]
  30. Michenfelder J. D., Theye R. A. The effects of anesthesia and hypothermia on canine cerebral ATP and lactate during anoxia produced by decapitation. Anesthesiology. 1970 Oct;33(4):430–439. doi: 10.1097/00000542-197010000-00013. [DOI] [PubMed] [Google Scholar]
  31. Moore W. S., Boren C., Malone J. M., Roon A. J., Eisenberg R., Goldstone J., Mani R. Natural history of nonstenotic, asymptomatic ulcerative lesions of the carotid artery. Arch Surg. 1978 Nov;113(11):1352–1359. doi: 10.1001/archsurg.1978.01370230142018. [DOI] [PubMed] [Google Scholar]
  32. Morawetz R. B., Zeiger H. E., McDowell H. A., Jr, McKay R. D., Varner P. D., Gelman S., Halsey J. H. Correlation of cerebral blood flow and EEG during carotid occlusion for endarterectomy (without shunting) and neurologic outcome. Surgery. 1984 Aug;96(2):184–189. [PubMed] [Google Scholar]
  33. Ojemann R. G., Crowell R. M., Roberson G. H., Fisher C. M. Surgical treatment of extracranial carotid occlusive disease. Clin Neurosurg. 1975;22:214–263. doi: 10.1093/neurosurgery/22.cn_suppl_1.214. [DOI] [PubMed] [Google Scholar]
  34. Podore P. C., DeWeese J. A., May A. G., Rob C. G. Asymptomatic contralateral carotid artery stenosis: a five-year follow-up study following carotid endarterectomy. Surgery. 1980 Dec;88(6):748–752. [PubMed] [Google Scholar]
  35. Sharbrough F. W., Messick J. M., Jr, Sundt T. M., Jr Correlation of continuous electroencephalograms with cerebral blood flow measurements during carotid endarterectomy. Stroke. 1973 Jul-Aug;4(4):674–683. doi: 10.1161/01.str.4.4.674. [DOI] [PubMed] [Google Scholar]
  36. Sundt T. M., Jr, Michenfelder J. D. Focal transient cerebral ischemia in the squirrel monkey. Effect on brain adenosine triphosphate and lactate levels with electrocorticographic and pathologic correlation. Circ Res. 1972 Jun;30(6):703–712. doi: 10.1161/01.res.30.6.703. [DOI] [PubMed] [Google Scholar]
  37. Sundt T. M., Jr, Sharbrough F. W., Anderson R. E., Michenfelder J. D. Cerebral blood flow measurements and electroencephalograms during carotid endarterectomy. J Neurosurg. 1974 Sep;41(3):310–320. doi: 10.3171/jns.1974.41.3.0310. [DOI] [PubMed] [Google Scholar]
  38. Sundt T. M., Jr, Sharbrough F. W., Piepgras D. G., Kearns T. P., Messick J. M., Jr, O'Fallon W. M. Correlation of cerebral blood flow and electroencephalographic changes during carotid endarterectomy: with results of surgery and hemodynamics of cerebral ischemia. Mayo Clin Proc. 1981 Sep;56(9):533–543. [PubMed] [Google Scholar]
  39. Sundt T. M., Sandok B. A., Whisnant J. P. Carotid endarterectomy. Complications and preoperative assessment of risk. Mayo Clin Proc. 1975 Jun;50(6):301–306. [PubMed] [Google Scholar]
  40. Thompson J. E. Complications of carotid endarterectomy and their prevention. World J Surg. 1979 Jul 16;3(2):155–165. doi: 10.1007/BF01561265. [DOI] [PubMed] [Google Scholar]
  41. Waltz A. G., Sundt T. M., Jr The microvasculature and microcirculation of the cerebral cortex after arterial occlusion. Brain. 1967 Sep;90(3):681–696. doi: 10.1093/brain/90.3.681. [DOI] [PubMed] [Google Scholar]
  42. Waltz A. G., Wanek A. R., Anderson R. E. Comparison of analytic methods for calculation of cerebral blood flow after intracarotid injection of 133 Xe. J Nucl Med. 1972 Jan;13(1):66–72. [PubMed] [Google Scholar]
  43. Whitney D. G., Kahn E. M., Estes J. W., Jones C. E. Carotid artery surgery without a temporary indwelling shunt. 1,917 consecutive procedures. Arch Surg. 1980 Nov;115(11):1393–1399. doi: 10.1001/archsurg.1980.01380110125020. [DOI] [PubMed] [Google Scholar]

Articles from Annals of Surgery are provided here courtesy of Lippincott, Williams, and Wilkins

RESOURCES