Carotid endarterectomy in awake patients with contralateral carotid arteryocclusion

Objectives: Patients with severe stenosis of an internal carotid artery wit h contralateraI occlusion (ICO) are at an increased risk for stroke, and th erefore surgical treatment Is usually recommended. Carotid endarterectomy ( CEA) under regional anesthesia enables constant; monitoring of neurologic s tatus and selective shunting in cases of clinically evident cerebral ischem ia, In this study, we assess the selective use of shunts based solely on ch anges in neurological status in awake patients with ICO undergoing CEA as w ell as their complication rates. Methods: During 1996-1998, we studied intraoperative findings and results o f CEA under regional anesthesia with clinical monitoring of neurological st atus in two groups: (1) patients with stenosis (>70% by NASCET) and contral ateral occlusion (n = 50) and (2) patients with stenosis and no contralater al occlusion (n = 94), Results: Shunt insertion was required in 42% of group 1, and 6% in group 2. All of the patients in group 1 requiring shunts had stump,pressures <50 to rr. The average stump pressure of group 1 (40 torr) was significantly lower than that of group 2(75 torr), and was also Lower than that of patients wi th severe contralateral stenosis (35 patients, 76 torr). Perioperative stro ke rates were identical in both groups (2.1%). Conclusion: Since ICO patients are at a high risk for brain ischemia during ICA cramping, they require shunt insertion frequently. Patients with no co ntralateral occlusion require shunting at a much lower rate - even in the p resence of severe contralateral stenosis. Regional anesthesia allows for ea rly detection of brain ischemia and therefore, the perioperative results In both groups are similar. (C) 2001 The International Society for Cardiovasc ular Surgery. Published by Elsevier Science Ltd. All rights reserved.