Is routine intravascular shunting necessary for carotid endarterectomy in patients with contralateral occlusion? A review of 5-year experience of carotid endarterectomy with local anaesthesia

Objectives. Endarterectomy of a stenotic internal carotid artery in the presence of contralateral carotid occlusion (CCO) is Often assessed as a high-risk procedure. We have assessed the requirementfor shunting in patients with CCO operated under local anaesthetic. Materials and methods. Between 1998 and 2003,429 patients (319 males and 110 females, mean age 65.7+/-6.2, range 4884) underwent 500 carotid endarterectomies under local anaesthetic with awake neurological testing. Fifty-five patients (12.8%) had CCO. Preoperative risk factors, intra- and postoperative events were noted and analyzed. Short-term and midterm follow-up (mean 16.4+/-5.8 months, range 3-38 months) was also recorded. Results. The rate of shunting in patients with or without CCO (10.9% vs. 9.1%,) was not significantly different. Stroke rates for CCO and non-CCO groups were 3.6 and 0.5%, respectively. Only the presence of preoperative cerebral infarction increased the risk of stroke. Patients that needed shunting were found to have significantly higher overall rate of adverse events, mortality and stroke. Conclusions. Routine use of intravascular shunting for a stenotic carotid artery with contralateral occlusion may not be necessary. The choice of using a shunt is safe when made intraoperatively by assessing the neurological status of the patient continuously. This requires expertise and strong cooperation between the anaesthesiologist and the surgical teams.