Our results with U-CEA confirm that this population has a higher risk profile compared with elective surgery. The type of acute presentation is correlated with perioperative risk. U-CEA was safe when performed on patients presenting with transient ischemic attack. An acceptable complication rate was achieved for patients with minor to moderate strokes. The poorest outcomes occurred in patients presenting with stroke in evolution: U-CEA in these patients should be offered with extreme caution, although we are aware that a conservative treatment may not grant a better prognosis.

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Results: 29/188 patients had an inappropriate bone window for TCD and another 3 patients lacked data concerning clamp-to-shunt time. There were no significant differences between the three groups in the following characteristics: sex, age, co-morbidity, patch/no-patch and symptomatic/ asymptomatic patients (t-tests). 30-day stroke/death rate increased with longer clamp-to-shunt time: 3,6%, 5,6% and 12,8% in group 1 (nϭ28), 2 (nϭ89), and 3 (nϭ39), respectively. We analyzed this effect using a binary logistic regression model and found a two-tailed p-value of 0,093. The confounding effect of peri-operative microembolic signals and intracranial flow decrease measured by TCD at 1 and 3 minutes after carotid cross clamping was controlled for.Conclusions: Longer carotid-clamp-to-shunt time tends to increase 30 day stroke/death rate post-CEA in our selective shunting protocol. When clamp-to-shunt time exceeded 7 minutes, more than 1 out of 8 patients ended with stroke or death. Again, time is brain! Objectives:A 20 year prospective experience with routine non-shunting during carotid endarterectomy (CEA), even in the presence of a contralateral internal carotid artery occlusion, is reviewed.Method: Carotid endarterectomy was performed under general anesthesia without a shunt in 2027 consecutive CEA procedures in1780 patients: 733 procedures were performed on females and 1294 on males with ages ranging from 37 to 97 years and a mean age of 73 years. Monitoring of cerebral blood flow and/or function was not utilized in any patient. Blood pressure was maintained above 130mmHg pharmacologically. Heparin (7500U) and protamine reversal were uniformly used.Results: A contralateral occlusion was present in 127 CEAs. 1344 CEAs were performed with a Dacron patch. Average cross clamp time was 18.5 minutes and 21 minutes for CEA without and with patches respectively (minimum 8 minutes and maximum 58 minutes). Average cross clamp time in the presence of a contralateral occlusion was 19.6 minutes. Overall, neurological complications occurred within thirty days in 33 (1.62%) patients (17 strokes [0.84%] and 16 transient ischemic attacks (TIAs) [0.79%]). There was only one stroke in a patient with a contralateral occlusion (0.79%). Immediate postoperative events, i.e. those that could be implicated as due to lack of a shunt, were rare (0.89%) (10 strokes [0.49%] and 8 TIAs, [0.39%]). There were 12 perioperative deaths (0.59%) 4 following a stroke (0.2%) and 7 (0.35%) due a cardiac event.Conclusion: Carotid endarterectomy may be performed safely without a shunt even in the presence of a contralateral occlusion. Further, contralateral occlusion does not appear to add additional risk to CEA and should not be considered a high risk for endarterectomy.

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