Introduction: Open surgical treatment of carotid artery stenosis, namely, carotid endarterectomy (CEA), has evolved since its inception in 1953. Despite improvements in the treatment of carotid occlusive disease through technological and surgical innovations, the use of patch grafting in CEAs remain controversial. We evaluate the durability of the primary closure and the safety of selective shunting during carotid endarterectomy (CEA) as determined by intraoperative electroencephalography (EEG) and postoperative outcomes.

Methods: A consecutive series of CEAs performed by the senior author at a single academic medical center from 2001 to 2012 were reviewed. All cases were performed under continuous intraoperative EEG. Patch angioplasty was used in cases where there was tortuosity of the vessel within the region of the endarterectomy and narrow vessel diameter at the distal end of the arteriotomy. Shunting was used when intraoperative EEG showed a > 50% reduction in a waveform in any lead. Patients were evaluated for restenosis via imaging or ultrasound at six months and subsequently annual follow-up.

Results: One hundred and forty-one CEAs were performed on 132 (76 male, 56 female) patients with an average age of 71 years (range: 40–95 years). Four (3%) cases required patch angioplasty and three (2%) required intraoperative shunts. The cross-clamp time ranged from 22 to 74 minutes, and the duration increased with the use of shunts and patches. Complications were rare and included recurrent stenosis (n=2), postoperative transient ischemic attack (n=1), ischemic stroke in (n=1), temporary hypoglossal nerve weakness (n=2), temporary marginal mandibular nerve weakness (n=6), and neck hematoma (n=1).

Conclusions: Intraoperative EEG data suggests that primary closure and selective shunting in CEAs can result in outcomes comparable with routine patch angioplasty and shunting.

Patient Care: The use of patch angioplasty and shunts during CEA remains controversial and their use remains dependent on the preference and experience of the surgeon. There is currently insufficient data in the literature on the risks and benefits associated with routine patch angioplasty and shunts during CEA. This retrospective series demonstrates that primary closure and selective shunting in CEA, based on intraoperative EEG monitoring, can result in outcomes comparable with routine use of patch angioplasty and shunts.

Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of open surgical treatment of carotid artery stenosis, namely, carotid endarterectomy 2) Discuss, in small groups, the risks and benefits of patch angioplasty and intraoperative shunting during carotid endarterectomy 3) Identify an effective treatment for carotid stenosis via carotid endarterecotomy and avoid the risks associated with patch angioplasty and intraoperative shunting.

References: Kapoor R, Evins A I, Marcus J, et al. (October 28, 2015) Selective Patch Angioplasty and Intraoperative Shunting in Carotid Endarterectomy: A Single-Center Review of 141 Procedures. Cureus 7(10): e367. DOI 10.7759/cureus.367