A prospective study of carotid endarterectomy with and without shunt.

The extent of cerebral protection necessary during carotid endarterectomy for ischemia is controversial. In 147 carotid endarterectomies, carotid backflow was estimated and, in later years, these clinical impressions were correlated with stump pressure. These estimates or values, modified particularly in early years by the extent of contralateral disease and (inversely) of ipsilateral occlusion, were used to determine the need for a shunt at the time of carotid clamping. Only 32 shunts were used, 12 because of poor back bleeding and 20 because of stump pressure below 50 mmHg. The patients who received shunts had no mortality or neurologic deficits. In 30 patients excluded by adequate stump pressure there was only a single minor and temporary monoparesis. In 85 patients excluded by apparently good back bleeding, there were two deaths (one due to stroke), a permanent 10 per cent neurologic deficit, and two postoperative thromboses salvageable by reoperation. Routine shunting would probably have prevented only the temporary monoparesis and the 10 per cent neurologic deficit. Meticulous technique and selective use of a shunt should give satisfactory results.