Shunt Intention During Carotid Endarterectomy in the Early Symptomatic Period and Perioperative Stroke Risk
Scott Levin1, Alik Farber1, Philip Goodney2, Marc Schermerhorn3, Virendra Patel4, Nkiruka Arinze1, Douglas Jones1, Jeffrey Siracuse1
1Boston University School of Medicine, Boston, MA 2Dartmouth-Hitchcock Medical Center, Lebanon, NH; 3Beth Israel Deaconess Medical Center, Boston, MA; 4Columbia University Medical Center, New York, NY, USA
Background: Whether recent stroke mandates shunting during carotid endarterectomy (CEA) is controversial. Our goal was to determine associations of various shunting practices with perioperative outcomes of CEAs performed after acute stroke.
Methods: The VQI database (2010-2018) was queried for CEAs performed within 14 days of ipsilateral stroke. Shunting practices included no shunting and routine, preoperatively indicated, or intraoperatively indicated shunting. These were further categorized into planned shunting (composite of routine/preoperatively indicated) and unplanned shunting (intraoperatively indicated).
Results: 5,683 CEAs were performed after acute stroke. Shunting cohorts included none (38.4%), planned (56.1%), and unplanned (5.5%). They differed by rates of severe contralateral carotid stenosis (6.9% vs. 8.8% vs. 6.8%), general anesthesia use (89.1% vs. 97.5% vs. 89%), and conventional CEA technique (81% vs. 94% vs. 87.7%) (P<.05 for all). Unadjusted outcomes differed for operative duration (122.6±47.5 vs. 124.3±48.1 vs. 130.3±42.8 minutes) and 30-day stroke (2.4% vs. 3.4% vs. 7.1%) (P<.05 for all), but not for mortality or MI. On multivariable analysis, 30-day stroke was associated with unplanned (OR 3.36, 95% CI 1.87-6.04, P<.001) and planned (OR 1.53, 95% CI 1.02-2.3, P=.04) shunting relative to no shunting. However, subgroup analysis revealed no difference between no shunting and routine shunting for stroke. Furthermore, non-routine compared with routine shunting predicted increased stroke (OR 1.76, 95% CI 1.23-2.53, P=.002).
Conclusion: In CEAs performed after acute stroke, no shunting was associated with relatively low perioperative stroke risk. Unplanned and planned shunting predicted increased risk of stroke, however shunting by non-routine shunters may account for this difference.
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