PREOPERATIVE VOLUME EXPANSION IMPROVES TOLERANCE TO CAROTID-ARTERY CROSS-CLAMPING DURING ENDARTERECTOMY

OBJECTIVE: The benefit of carotid endarterectomy for carotid artery st enosis relates to both appropriate patient selection and careful surgi cal technique. Critical to the latter is the ability to afford intraop erative neuroprotection during carotid cross-clamping, although the op timal strategy to assure this protection remains debated. This report describes the impact of adding preoperative colloid volume expansion t o a surgical algorithm that includes electroencephalographic (EEG) mon itoring and barbiturate-induced burst suppression for EEG lateralizati on refractory to hypertension. METHODS: The incidence of ischemic EEG change during carotid cross-clamping was observed. The results of an i nitial series of patients (n = 45) reported before incorporation of vo lume expansion were compared with the results of the current series (n = 155) of carotid endarterectomies, which included preoperative volum e expansion with 6% hetastarch (500 or 1000 cc). RESULTS: With preoper ative volume expansion, there was a 40% decrease in the incidence of E EC lateralization during carotid cross-clamping (17.4 versus 28.9%, P < 0.05) and a 63% decrease in the EEC lateralization refractory to ind uced hypertension (5.8 versus 15.6%, P < 0.05). The combined periopera tive stroke and death rate was 1.3%. CONCLUSION: These results support the use of preoperative colloid volume expansion in carotid endartere ctomy as a means of increasing the cerebral tolerance to carotid cross -clamping.