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Selective internal carotid artery cross-clamping increases the specificity of cerebral oximetry for indication of shunting during carotid endarterectomy

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Abstract

Background

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.

Methods

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.

Results

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%.

Conclusions

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.

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Funding

The Internal Grant Agency of the Krajská zdravotní provided financial support in the form of a grant (IGA-KZ-2017-1-13). The Health Research Council of the Czech Republic provided a grant NV19-04-00270. The sponsors had no role in the design or conduct of this research.

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Authors and Affiliations

  1. Neurosurgery Department, Masaryk Hospital, J. E. Purkyně University, Sociální péče 12A, 401 13, Ústí nad Labem, Czech Republic

    A. Hejčl, A. Malucelli, A. Sejkorová, T. Radovnický, R. Bartoš, M. Orlický & M. Sameš

  2. International Clinical Research Center, St. Anne’s Hospital, Brno, Czech Republic

    A. Hejčl

  3. Institute of Experimental Medicine, Academy of Sciences of the Czech Republic, Prague, Czech Republic

    A. Hejčl

  4. 2nd Faculty of Medicine, Charles University, Prague, Czech Republic

    K. Jiránková

  5. Department of Neurology, Masaryk Hospital, Ústí nad Labem, Czech Republic

    Š. Brušáková

  6. Faculty of Health Studies, J. E. Purkyne University, Ústí nad Labem, Czech Republic

    K. Hrach

  7. Department of Anesthesiology, Intensive Care and Perioperative Medicine, Masaryk Hospital, J. E. Purkyne University, Ústí nad Labem, Czech Republic

    J. Kastnerová

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  1. A. Hejčl
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Corresponding author

Correspondence to A. Hejčl.

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The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee (Ethical Committee of the Krajská zdravotní) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

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Comments

We have here an outstanding clinical investigation by an experienced carotid surgery group. The study goal was to validate bilateral NIRS CO decreases with neurologic deterioration in awake patients, and thereby to establish a critical NIRS value to indicate the need for indwelling shunt.

The method was well conceived and elegant. Patients were monitored for CO with forehead NIRS monitors, and were also operated under loco-regional anesthesia. In this way the accuracy of the NIRS could be validated, but the shunting decision was actually made by direct observation of the patient for neurological changes.

One hundred and five patients (85%) were stable throughout the CEA, while 20 patients (15%) clinically deteriorated during surgery. The mean drop in the cerebral oximetry 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 cut-off value for selective shunting was set as a 10% decrease of the ipsilateral cerebral oximetry after selective ICA clamping, the sensitivity of the technique was 100% and the specificity 83.0%.

As side observations, female sex and contralateral stenosis/occlusion were significant risk factors for shunt placement.

The series is not completely pure, since for various reasons 5% of the patients were not shunted despite a neurological change suggesting that shunt placement would be beneficial (the unstable group). Four patients (3.2% of the series) in the unstable group suffered strokes; it is unclear whether these patients were the non-shunted patients or shunted patients, but this is of concern.

DWI MRI studies were done postop in 120/125 patents and the results are fascinating. In the group of stable patients (n = 100), they observed a new lesion in 8 (8%). In the patients with clinical deterioration (n = 20), they observed a new ischemic lesion in 11 (55.0%) patients (p < 0.001). Clearly even most patients with DWI lesions were clinically well, but it is interesting and worrisome that patients showed DWI lesions despite successful shunt placement.

My personal technique is somewhat different, and my shunt placement rate is a little higher. I use combined EEG/SSEP monitoring and general anesthesia for CEA. We shunt for any change at all in either EEG or SSEP, or both. With this technique I shunt 15% of patients, and 25% if there is contralateral occlusion, strictly by following the monitoring (1).

The authors conclude that a 10% decrease in the ipsilateral brain tissue oximetry after selective cross-clamping of the ICA provides a reliable cut-off value for selective shunting during CEA. I agree with this, and I believe their study is a true contribution to our knowledge of selective shunting and patient protection for best outcomes.

Christopher Miranda Loftus

PA, USA

1. Loftus CM: Carotid Artery Surgery: Principles and Technique. 2nd edition. New York, Informa Publishing 2006.

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This article is part of the Topical Collection on Vascular Neurosurgery - Ischemia

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Hejčl, A., Jiránková, K., Malucelli, A. et al. Selective internal carotid artery cross-clamping increases the specificity of cerebral oximetry for indication of shunting during carotid endarterectomy. Acta Neurochir 163, 1807–1817 (2021). https://doi.org/10.1007/s00701-020-04621-1

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