Shunt Intention During Eversion Carotid Endarterectomy and Perioperative Stroke Risk
Scott R. Levin, M.D., M.Sc.1, Alik Farber, M.D., M.B.A.1, Philip P. Goodney, M.D., M.S.2, Virendra I. Patel, M.D., M.P.H.3, Rebecca Hasley, M.D.1, Nkiruka Arinze, M.D.1, Thomas W. Cheng, M.D.1, Denis Rybin, Ph.D.1, Jeffrey J. Siracuse, M.D., M.B.A.1
1Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA 2Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, The Dartmouth Institute for Health Policy and Clinical Practice, Hanover NH 3Division of Vascular Surgery and Endovascular Interventions, Columbia University Medical Center, New York, NY
Background: 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 whether surgeons prospectively planned or planned not to shunt. Secondarily, we sought to compare outcomes based on shunting indication.
Methods: The Vascular Quality Initiative (2011-2019) was queried for eCEAs. Outcomes were compared based on 1) whether surgeons planned or planned not to shunt and 2) whether shunting was routine practice, preoperatively indicated, intraoperatively indicated, or not performed.
Results: Among 13,207 eCEAs, surgeons planned to shunt in 3,605 (27.2%) cases. When surgeons planned to shunt, compared with planned not to shunt, patients experienced similar 30-day stroke (.7% vs .8%, P=.49) and mortality (.6% vs .6%, P=.68), but longer operative duration (116.8±49.4 vs 107.1±44.6 minutes, P<.001). On multivariable analysis, planning compared with planning not to shunt was associated with similar stroke and mortality risk, but with increased operative duration (OR 1.2, 95% CI 1.14-1.18, P<.001). Among eCEAs, shunting was routine in 25.4%, preoperatively indicated in 1.9%, intraoperatively indicated in 4.7%, and not performed in 68%. Compared to no shunting, routine and preoperatively indicated shunting were each associated with similar stroke risk, but intraoperatively indicated shunting was associated with increased stroke risk (OR 2.74, 95% CI 1.41-5.3, P.003).
Conclusion: In eCEA, there is no difference in perioperative stroke risk when surgeons prospectively plan or plan not to shunt. When shunting is performed, shunting planned in advance is associated with lower stroke risk.
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