Shunting during carotid endarterectomy

AbuRahma, Ali F.; Mousa, Albeir Y.; Stone, Patrick A.

doi:10.1016/j.jvs.2011.06.020

Cited by 115 publications

(90 citation statements)

References 65 publications

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“…10,12 In either case, the shunting procedure comes not without potential for additional cost and with little to no systemic analytical support. 7,8,11 Proponents for patch closure endarterectomy argue that the procedure helps to prevent the occurrence of early thrombosis and late re-stenosis of the carotid artery. However, such data may fail to show usefulness in stroke.…”

Section: Discussionmentioning

confidence: 99%

“…[3][4][5] The overall results that specifically compare one technique to another, however, remain less clear. [6][7][8][9] The argument for the practicality of shunt placement stems from the potential reduction of perioperative stroke risk through the minimization of the loss of cerebral blood flow during clamping. Advocates of routine shunting suggest that the technique increases surgeon experience and reduces time spent with patient neurological monitoring.…”

Section: Discussionmentioning

confidence: 99%

“…Currently, there is wide variability in technique of this operation and limited statistical evidence regarding the risks and benefits of one particular method versus another. [6][7][8][9] With procedural variability potentially leading to an increase in the amount of dollars spent per procedure, 10 we decided to investigate the procedural variability of CEA at the University of Kentucky Medical Center with a focus on hospital outcomes, 30-day morbidity and mortality, and cost.…”

mentioning

confidence: 99%

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Variability in Carotid Endarterectomy at a Single Medical Center: An Outcome and Cost Analysis

Saha

Rodgers-Fischl²,

Minion³

et al. 2012

Int J Angiol

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Stroke is the leading cause of long-term disability in the United States and the fourth leading cause of mortality. 1 Over 87% of those strokes are of ischemic origin, and $ 20% of this subset is due to large artery stenosis. 2 A reduction in stroke rate in patients with carotid artery stenosis could therefore result in an overall reduction in mortality and morbidity due to stroke and substantially affect cost and savings.Carotid endarterectomy (CEA) is a common surgical procedure proven in large clinical trials to cost effectively reduce stroke risk and recurrence in patients with symptomatic and/ or asymptomatic large artery stenosis. 3-5 CEA and arterial reconstruction can be performed in a variety of ways including standard endarterectomy with primary closure, standard endarterectomy with patch closure, shunt-placed endarterectomy with primary closure, and shunt-placed endarterectomy with patch closure. Currently, there is wide variability in technique of this operation and limited statistical evidence regarding the risks and benefits of one particular method versus another. 6-9 With procedural variability potentially leading to an increase in the amount of dollars spent per procedure, 10 we decided to investigate the procedural variability of CEA at the University of Kentucky Medical Center with a focus on hospital outcomes, 30-day morbidity and mortality, and cost. MethodsWe reviewed the charts of a consecutive series of 349 patients undergoing CEA at our institution. We analyzed the variability in shunt used across surgeons, intraoperative variables, cost, and outcome. AbstractCarotid endarterectomy (CEA) is a common surgical procedure. Its efficacy in the prevention of stroke has been proven by multiple clinical trials including North American Symptomatic Carotid Endarterectomy Trial and Asymptomatic Carotid Atherosclerosis Study. Currently, there is a wide variability in the technique of this operation. This study was performed to determine the variability of CEA at the University of Kentucky Medical Center with a focus on cost and short-term outcome. We reviewed the charts of a consecutive series of 349 patients undergoing CEA at our institution. We analyzed the variability in shunt used across surgeons, intraoperative variables, cost, and outcome. Data on 374 procedures on 349 patients who underwent CEA showed shunt utilization varied significantly by surgeon from 3 to 94%. Patch utilization also varied significantly by surgeon. Two in-hospital deaths occurred in the shunt group (1.3%) and none in the no-shunt group. Shunt placement was associated with 1 hour 24 minutes increase in operative time from 2 hours 3 minutes in the no-shunt group to 3 hours 27 minutes in the shunt group (t test, p < 0.01). Shunt placement was associated with a 1.74-day increase in length of stay, from 2.97 days in the no-shunt group to 4.71 days in the shunt group. There was no significant difference in the cost of procedure in these two groups: no-shunt $11,510 AE $3,977, shunt group $11,479 AE $4,030. This study showed no...

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

See 1 more Smart Citation

Variability in Carotid Endarterectomy at a Single Medical Center: An Outcome and Cost Analysis

Saha

Rodgers-Fischl²,

Minion³

et al. 2012

Int J Angiol

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show abstract

“…The Cochrane Library has conducted metaanalyses with different upgrades including quasi and randomized trials published until 2013 comparing the use of routine shunting with no shunting or selective shunting and have not found statistically significant results in favour of any of the options, keeping all of them low rates of perioperative ischemic stroke [42]. We should note that they have been described different complications during insertion of the shunt as the possibility of distal carotid dissection, pseudo aneurysm, air or atheromatous distal embolization, acute arterial occlusion, nerve damage, hematoma, infection and even long-term restenosis [ 43,44,45]. The guides belonging to international societies of Vascular Surgery, allow the surgical team to choose the placement or not of the shunt according to professional experience.…”

Section: Carotid Shuntmentioning

confidence: 99%

Carotid Stenosis and Anaesthesia

Jj¹,

A²,

Jl³

et al. 2016

Int J Surg Surgical Proced

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EpidemiologyThe importance of carotid stenosis approach lies in the relationship it has with ischemic stroke, since it is present in 10-20% of all of them. This is of magnitude when we know that in Western countries, stroke is the third leading cause of death, behind only heart disease and cancer, with a mortality ranging from 10 to 30%, having survivors risk of recurring ischemic cardiac or neurologic events, so much so that is the leading cause of disability. The prevalence of stenosis in the internal carotid artery (ICA) is high and furthermore increases with age, in fact more than 50% stenosis rises from 0.5% in people aged between 50 and 59 years to 10% in those over 80 years. The primary mechanism involved in stroke in patients with carotid stenosis is embolism of atherosclerotic or thrombotic waste material from the plate to the distal cerebral vasculature. Infiltration of inflammatory cells on the surface of carotid plaques can play a key role in causing plaque rupture and embolization or occlusion of the carotid and also hemodynamic factors are correlated with increased risk of stroke in patients with carotid stenosis [1,2,3]. Of all the factors studied, the degree of arterial stenosis has emerged as the most directly related to the increased risk of stroke. Any diagnostic strategy, whatever the technique used, should have as its primary objective to determine, in the most accurate way, the amount of this stenosis [4].In the NASCET study the risk of ipsilateral recurrent stroke in patients with symptomatic carotid stenosis treated conservatively was 4.4% per year for patients with stenosis between 50 and 69% and 13% per year for those with 70% stenosis. The risk in patients with asymptomatic stenosis of 60% was around 1-2%, but could rise to 3-4% per year in elderly patients or in the presence of stenosis or occlusion of the contralateral artery, evidence of silent embolization in an imaging test, heterogeneity of the carotid plaque, poor collateral circulation, generalized inflammatory state or peripheral or coronary artery disease associated [5]. Treatment Medical versus interventional treatmentGiven the above discussion, we will assume that the main objective in the treatment of carotid stenosis is the prevention of ischemic stroke and its aftermath, regardless of the type of patient, the presence or absence of symptoms and the degree of stenosis. However, despite the clarity of the target it is unclear what therapeutic option to choose among only medical treatment or revascularization and, in the latter case, between endoluminal or surgical treatment. We will be guided in this review [6], considering that these guidelines place more emphasis on stroke prevention in the prevention of ischemic heart disease, on the grounds that according to the CREST study, stroke has shown greater impact on quality of life of the patient than nonfatal myocardial ischemia [7].The major determinants of the clinical course are the presence or absence of neurological symptoms and the degree of stenosis. The threat of isc...

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“…[2][3][4][5] Nevertheless, many aspects of CEA remain controversial in the vascular surgery community including endarterectomy technique, shunt use, protamine use, and completing imaging with variations in practice preferences. [6][7][8][9][10][11] It has been demonstrated in numerous areas of medicine in the United States that variability in the delivery of care results in higher costs with no measurable differences in outcomes. [12][13][14][15] In the area of peripheral arterial disease, revascularization has been shown to be associated with higher spending, but higher spending is not associated with lower amputation rates.…”

Section: Introductionmentioning

confidence: 99%

Carotid Endarterectomy in the Southern California Vascular Outcomes Improvement Collaborative

Chan

Abou-Zamzam

Woo

2016

Annals of Vascular Surgery

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Shunting during carotid endarterectomy

Abstract: The use of routine shunting and selective shunting was associated with a low stroke rate. Both methods are acceptable, and the individual surgeon should select the method with which they are more comfortable.

Cited by 115 publications

References 65 publications

Variability in Carotid Endarterectomy at a Single Medical Center: An Outcome and Cost Analysis

Variability in Carotid Endarterectomy at a Single Medical Center: An Outcome and Cost Analysis

Carotid Stenosis and Anaesthesia

Carotid Endarterectomy in the Southern California Vascular Outcomes Improvement Collaborative

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