Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA.
J Vasc Surg. 2010 May;51(5):1133-8. doi: 10.1016/j.jvs.2009.12.046. Epub 2010 Mar 29.
The use of shunting in carotid endarterectomy (CEA) is controversial. This randomized trial compared the results of routine (RS) vs selective shunting (SS) based on stump pressure (SP).
Two-hundred CEA patients under general anesthesia were randomized into RS (98 patients) or SS (102 patients), where shunting was used only if systolic SP (SSP) was <40 mm Hg. Clinical and demographic characteristics were comparable in both groups. Patients underwent immediate and 30-day postoperative duplex ultrasound follow-up. Analysis was by intention-to-treat.
Of 102 SS patients, 29 (28%) received shunting. Indications for CEA were similar (42% symptomatic for RS; 47% for SS, P = .458). The mean internal carotid artery diameter was comparable (5.5 vs 5.5 mm, P = .685). Mean preoperative ipsilateral and contralateral stenosis was 76% and 38% for RS (P = .268) vs 78% and 40% for SS (P = .528). Mean preoperative ipsilateral and contralateral stenosis was 79% and 56% in the shunted (P = .634) vs 78% and 34% in the nonshunted subgroup of SS patients (P = .002). The mean SSP was 55.9 mm Hg in RS vs 56.2 for SS (P = .915). The mean SSP was 33 mm Hg in the shunted vs 65 in the nonshunted subgroup (P < .0001). Mean clamp time in the nonshunted subgroup of SS was 32 minutes. Mean shunt time was 35 minutes in RS and 33 in SS (P = .354). Mean operative time was 113 minutes for RS and 109 for SS (P = .252), and 111 minutes in shunted and 108 in the nonshunted subgroup (P = .586). Mean arteriotomy length was 4.4 cm for RS and 4.2 for SS (P = .213). Perioperative stroke rate was 0% for RS vs 2% for SS (one major and one minor stroke, both related to carotid thrombosis; P = .498). No patients died perioperatively. Combined perioperative transient ischemic attack (TIA) and stroke rates were 2% in RS vs 2.9% in SS (P > .99). The overall perioperative complication rates were 8.3% in RS (2 TIA, 3 hemorrhage, 1 myocardial infarction [MI], and 1 asymptomatic carotid thrombosis) vs 7.8% in SS (2 strokes, 1 TIA, 3 hemorrhage, 1 MI, and 1 congestive heart failure; P = .917).
RS and SS were associated with a low stroke rate. Both methods are acceptable, and surgeons should select the method with which they are more comfortable.
在颈动脉内膜切除术（CEA）中使用分流存在争议。本随机试验比较了基于残端压力（SP）的常规分流（RS）与选择性分流（SS）的结果。
200 例全身麻醉下接受 CEA 的患者被随机分为 RS（98 例）或 SS（102 例），仅在收缩期 SP（SSP）<40mmHg 时使用分流。两组的临床和人口统计学特征相似。患者接受即刻和 30 天术后双功超声随访。分析采用意向治疗。
在 102 例 SS 患者中，29 例（28%）接受了分流。CEA 的适应证相似（RS 组 42%为症状性；SS 组 47%为症状性，P=0.458）。颈内动脉直径相似（RS 组为 5.5mm；SS 组为 5.5mm，P=0.685）。RS 组术前同侧和对侧狭窄程度分别为 76%和 38%（P=0.268），SS 组分别为 78%和 40%（P=0.528）。RS 组分流的同侧和对侧狭窄程度分别为 79%和 56%（P=0.634），SS 组无分流的同侧和对侧狭窄程度分别为 78%和 34%（P=0.002）。RS 组 SSP 平均为 55.9mmHg，SS 组为 56.2mmHg（P=0.915）。RS 组分流的 SSP 平均为 33mmHg，SS 组无分流的 SSP 平均为 65mmHg（P<0.0001）。SS 组无分流的 SSP 平均夹闭时间为 32 分钟。RS 组的平均分流时间为 35 分钟，SS 组为 33 分钟（P=0.354）。RS 组的平均手术时间为 113 分钟，SS 组为 109 分钟（P=0.252），SS 组分流的手术时间为 111 分钟，无分流的手术时间为 108 分钟（P=0.586）。RS 组的动脉切口长度为 4.4cm，SS 组为 4.2cm（P=0.213）。RS 组围手术期卒中发生率为 0%，SS 组为 2%（1 例主要和 1 例次要卒中，均与颈动脉血栓形成有关；P=0.498）。无患者围手术期死亡。RS 组的围手术期短暂性脑缺血发作（TIA）和卒中总发生率为 2%，SS 组为 2.9%（P>0.99）。RS 组的围手术期总并发症发生率为 8.3%（2 例 TIA，3 例出血，1 例心肌梗死[MI]和 1 例无症状性颈动脉血栓形成），SS 组为 7.8%（2 例卒中，1 例 TIA，3 例出血，1 例 MI 和 1 例充血性心力衰竭；P=0.917）。
RS 和 SS 与低卒中率相关。两种方法均可行，外科医生应选择其更熟悉的方法。
