Neurosurgery Department, Masaryk Hospital, J. E. Purkyně University, Sociální péče 12A, 401 13, Ústí nad Labem, Czech Republic.
International Clinical Research Center, St. Anne's Hospital, Brno, Czech Republic.
Acta Neurochir (Wien). 2021 Jun;163(6):1807-1817. doi: 10.1007/s00701-020-04621-1. Epub 2020 Oct 27.
An indication for selective shunting during carotid endarterectomy (CEA) is based on monitoring during a procedure. Cerebral oximetry (CO) using near-infrared spectroscopy (NIRS) may be a simple technique, but its relevance during CEA, especially with respect to cutoff values indicating shunt implantation, still needs to be elucidated.
One hundred twenty five patients underwent CEA under local anesthesia (LA) and were monitored clinically throughout the whole procedure. The patients were also monitored using bilateral NIRS probes during surgery. The NIRS values were recorded and evaluated before and after selective cross-clamping, firstly by the external carotid artery (ECA), followed by the internal carotid artery (ICA). The decrease in the ipsilateral CO values, with respect to the indication of shunting, was only analyzed after selective cross-clamping of the ICA. The decision to use an intraluminal shunt was solely based on the neurological status evaluation after ICA cross-clamping.
One hundred five patients (85%) were stable throughout the CEA, while 20 patients (15%) clinically deteriorated during surgery. The mean drop in the CO after selective ICA clamping in clinically stable patients was 6%, while in patients with clinical deterioration, the NIRS decreased by 14.5% (p < 0.05). When the cutoff value for selective shunting was set as a 10% decrease of the ipsilateral CO after selective ICA clamping, the sensitivity of the technique was 100% and the specificity 83.0%.
Our study showed that a 10% decrease in the ipsilateral brain tissue oximetry after selective cross-clamping the ICA provides a reliable cutoff value for selective shunting during CEA. Despite the availability of a variety of monitoring tools, the NIRS may be an easy, reliable option, especially in the scenario of acute CEA in general anesthesia.
颈动脉内膜切除术 (CEA) 中选择性分流的指征基于术中监测。近红外光谱 (NIRS) 脑氧饱和度 (CO) 可能是一种简单的技术，但在 CEA 中其相关性，特别是指示分流植入的截止值，仍需要阐明。
125 例患者在局部麻醉 (LA) 下行 CEA，并在整个手术过程中进行临床监测。在手术过程中，患者还使用双侧 NIRS 探头进行监测。在选择性夹闭前和夹闭后记录和评估 NIRS 值，首先是通过颈外动脉 (ECA)，然后是颈内动脉 (ICA)。仅在选择性夹闭 ICA 后分析同侧 CO 值相对于分流指征的下降情况。使用腔内分流器的决定完全基于 ICA 夹闭后神经状态评估。
105 例患者（85%）在 CEA 过程中稳定，20 例患者（15%）在手术中临床恶化。在临床稳定的患者中，选择性 ICA 夹闭后 CO 下降的平均值为 6%，而在临床恶化的患者中，NIRS 下降了 14.5%（p<0.05）。当选择性分流的截止值设定为选择性夹闭 ICA 后同侧 CO 下降 10%时，该技术的敏感性为 100%，特异性为 83.0%。
我们的研究表明，选择性夹闭 ICA 后同侧脑组织氧饱和度下降 10%可提供可靠的 CEA 中选择性分流截止值。尽管有多种监测工具可用，但 NIRS 可能是一种简单、可靠的选择，尤其是在全身麻醉下急性 CEA 的情况下。
