Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA.
Department of Biostatistics, Boston University School of Public Health, Boston, MA.
Ann Vasc Surg. 2022 Nov;87:362-368. doi: 10.1016/j.avsg.2022.05.046. Epub 2022 Jul 6.
Shunting during eversion carotid endarterectomy (eCEA) may be technically challenging. Whether shunting practice patterns modify perioperative stroke risk after eCEA is unclear. We aimed to compare eCEA outcomes based on shunting practice.
The Vascular Quality Initiative (2011-2019) was queried for eCEAs performed for symptomatic and asymptomatic carotid stenosis. Univariable and multivariable analyses compared outcomes based on whether shunting was routine practice, preoperatively-indicated, intraoperatively-indicated, or not performed.
There were 13,207 eCEAs identified. Average age was 71.4 years and 59.4% of patients were male sex. Ipsilateral carotid stenosis was >80% in 45.6% and there was severe contralateral carotid stenosis in 8.6%. Early ipsilateral symptoms within 14 days of eCEA were transient ischemic attack in 5.6% and stroke in 7%. The majority of cases were performed under general anesthesia (82.7%). Electroencephalogram monitoring and stump pressures were utilized in 30.9% and 14.7%, respectively. Shunting was routine (25.4%), preoperatively-indicated (1.9%), intraoperatively-indicated (4.7%), or not implemented (68%). Preoperatively-indicated shunting was more often performed in patients with early symptomatic carotid stenosis or severe contralateral carotid stenosis. After routine shunting, preoperatively-indicated shunting, intraoperatively-indicated shunting, and no shunting, median operative duration was 110, 101, 112, and 97 min, respectively (P < 0.001), and ipsilateral perioperative stroke prevalence was 0.6%, 1.2%, 1.9%, and 0.7%, respectively (P = 0.004). On multivariable analysis, longer operative time was associated with routine shunting (MR 1.17, 95% CI 1.15-1.19, P < 0.001), preoperatively-indicated shunting (MR 1.09, 95% CI 1.04-1.15, P < 0.001), and intraoperatively-indicated shunting (MR 1.12, 95% CI 1.09-1.16, P < 0.001) compared with no shunting. Compared with no shunting, routine shunting (OR 0.91, 95% CI 0.54-1.54, P = 0.74) and preoperatively-indicated shunting (OR 1.53, 95% CI 0.47-4.99, P = 0.48) were not associated with stroke; however, intraoperatively-indicated shunting was associated with increased stroke (OR 2.74, 95% CI 1.41-5.3, P = 0.003). Shunting type was not associated with perioperative mortality.
Intraoperatively-indicated shunting during eCEA was associated with longest operative duration and increased perioperative stroke risk. Surgeon familiarity with shunting and planning to shunt in advance may permit more expeditious shunting and prevent stroke.
外翻颈动脉内膜切除术（eCEA）过程中的转流可能具有技术挑战性。eCEA 后围手术期卒中风险是否因转流实践模式的改变而改变尚不清楚。我们旨在比较基于转流实践的 eCEA 结果。
血管质量倡议（2011-2019 年）被查询了症状性和无症状性颈动脉狭窄的 eCEA。单变量和多变量分析比较了是否常规进行转流、术前指示、术中指示或不进行转流的情况下的结果。
共确定了 13207 例 eCEA。平均年龄为 71.4 岁，59.4%的患者为男性。同侧颈动脉狭窄>80%的占 45.6%，严重对侧颈动脉狭窄的占 8.6%。eCEA 后 14 天内同侧出现早期症状为短暂性脑缺血发作的占 5.6%，卒中的占 7%。大多数病例在全身麻醉下进行（82.7%）。脑电图监测和残端压力分别应用于 30.9%和 14.7%的病例。转流为常规（25.4%）、术前指示（1.9%）、术中指示（4.7%）或未实施（68%）。术前指示性转流更常应用于早期有症状性颈动脉狭窄或严重对侧颈动脉狭窄的患者。在常规转流、术前指示性转流、术中指示性转流和无转流后，中位手术时间分别为 110、101、112 和 97 分钟（P<0.001），同侧围手术期卒中发生率分别为 0.6%、1.2%、1.9%和 0.7%（P=0.004）。多变量分析显示，常规转流（MR 1.17，95%CI 1.15-1.19，P<0.001）、术前指示性转流（MR 1.09，95%CI 1.04-1.15，P<0.001）和术中指示性转流（MR 1.12，95%CI 1.09-1.16，P<0.001）与无转流相比，手术时间更长。与无转流相比，常规转流（OR 0.91，95%CI 0.54-1.54，P=0.74）和术前指示性转流（OR 1.53，95%CI 0.47-4.99，P=0.48）与卒中无关；然而，术中指示性转流与卒中增加相关（OR 2.74，95%CI 1.41-5.3，P=0.003）。转流类型与围手术期死亡率无关。
外翻颈动脉内膜切除术过程中的术中指示性转流与最长的手术时间和增加的围手术期卒中风险相关。术者对转流的熟悉程度和提前计划转流可能会使转流更加迅速，并防止卒中的发生。
