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Combined Stump Pressure and Oximetry for Shunt Use During Carotid Endarterectomy

  • J. Max Findlay (a1), Rohit Kesarwani (a1), Michael Jacka (a2) and B. Elaine Marchak (a2)

Abstract

Background: Cross-clamp ischemia during carotid endarterectomy can be prevented with carotid bypass shunts in vulnerable patients identified by cerebral monitoring for ischemia. We compared transcranial cerebral oximetry (TCO) with carotid stump pressure measurements for selective shunt use. Methods: We prospectively collected data on 300 consecutive patients operated on under general anesthesia between 2009 and 2016. Shunts were inserted for a 10% or greater drop in cerebral saturations and/or a mean stump pressure less than 40 mmHg. Results: Seventy-five patients, 25% of the study population, were shunted. The indication was a combined desaturation and stump pressure in 38 (50% of the shunted group), desaturation alone in 11 patients (15%), and a low stump pressure alone in 26 patients (35%). There were no significant differences in baseline characteristics between those patients who were or were not shunted, except angiographic collateral blood supply, which was more commonly identified in patients who were not shunted. A watershed infarct occurred in just one patient with borderline TCO and stump pressure measurements in whom a shunt was not used. Conclusions: There was poor concordance between TCO and stump pressures, but using both in determining the need for shunt use almost eliminated cross-clamp ischemia in this series of 300 carotid endarterectomy patients.

Mesurer la pression distale au clamp et l’oxymétrie cérébrale en lien avec l’utilisation d’un tuyau de dérivation lors d’une endartériectomie carotidienne. Contexte: L’ischémie produite par l’utilisation d’un clamp lors d’une endartériectomie carotidienne peut se prévenir, chez des patients vulnérables dépistés par monitorage cérébral, au moyen de tuyaux de dérivation (shunts). Nous avons ainsi comparé les mesures de pression de l’oxymétrie cérébrale à celles de la pression distale au clamp (stump pressure) lorsque de tels tuyaux sont utilisés. Méthodes: Nous avons recueilli de façon prospective des données chez 300 patients consécutifs ayant subi, entre 2009 et 2016, une intervention sous anesthésie générale. Des tuyaux de dérivation ont ainsi été insérés lorsque survenaient une chute de saturation cérébrale en oxygène de 10 % ou plus et/ou une chute de la pression distale au clamp moyenne de moins de 40 mmHg. Résultats: Soixante-quinze patients, soit 25% de notre échantillon, ont bénéficié d’une dérivation de type « shunt ». Trente-huit d’entre eux, soit environ 50 % de l’échantillon, ont montré à la fois une chute de la pression distale au clamp et une désaturation cérébrale. Chez 11 patients (15 %), on a seulement observéun phénomène de désaturation alors qu’on a pu observer chez 26 d’entre eux (35 %) une baisse de la pression distale au clamp. Si l’on compare les patients ayant bénéficié d’une dérivation de type « shunt aux autres patients, nous n’avons noté, hormis le flux sanguin collatéral, plus fréquemment mesuré par angiographie chez les patients privés d’une dérivation, aucune différence importante quant à leurs caractéristiques respectives de départ. Fait à souligner, un seul patient, chez qui on avait enregistré des valeurs limites d’oxymétrie cérébrale et de pression distale au clamp et qui n’avait pas bénéficié de dérivation, a été victime d’un AVC ischémique jonctionnel (watershed infarct). Conclusions: Une faible concordance existe donc entre les mesures de pression de l’oxymétrie cérébrale et celles de la pression distale au clamp. Toutefois, le fait d’utiliser ces deux formes de monitorage pour déterminer s’il était nécessaire de procéder à une dérivation a pratiquement éliminé les cas d’ischémie produits par l’utilisation d’un clamp au sein de ce groupe de 300 patient soumis à une endartériectomie carotidienne.

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Copyright

Corresponding author

Correspondence to: J. Max Findlay, University of Alberta Hospital – Medicine, 2D1.02 WMC, 8440 112 Street, Edmonton, Alberta, Canada, T6G 2B7. Email: max.findlay@ahs.ca

References

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Keywords

Combined Stump Pressure and Oximetry for Shunt Use During Carotid Endarterectomy

  • J. Max Findlay (a1), Rohit Kesarwani (a1), Michael Jacka (a2) and B. Elaine Marchak (a2)

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