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Impact of external carotid artery occlusion at declamping of the external and common carotid arteries during carotid endarterectomy on development of new postoperative ischemic cerebral lesions.
J Vasc Surg 2019; 69(2):454-461JV

Abstract

OBJECTIVE

The external carotid artery (ECA) is inadvertently occluded during carotid endarterectomy (CEA). The importance of ECA occlusion has been emphasized as a loss of extracranial to intracranial collaterals, a source of chronic embolization, or a site for extended thrombosis during wound closure. This study aimed to determine whether ECA occlusion that inadvertently developed during endarterectomy and that was eventually detected using blood flow measurement of the ECA after declamping of all carotid arteries is a risk factor for development of new postoperative ischemic lesions at declamping of the ECA and common carotid artery (CCA) while clamping the internal carotid artery (ICA). This study also aimed to determine whether intraoperative transcranial Doppler (TCD) monitoring predicts the risk for development of such lesions.

METHODS

This was a prospective observational study that included patients undergoing CEA for severe stenosis (≥70%) of the cervical ICA. When blood flow through the ECA measured using an electromagnetic flow meter decreased rapidly on clamping of only the ECA before carotid clamping for endarterectomy and was not changed by clamping of only the ECA after carotid declamping following endarterectomy, the patient was determined to have developed ECA occlusion. These patients underwent additional endarterectomy for the ECA. TCD monitoring in the ipsilateral middle cerebral artery was also performed throughout surgery to identify microembolic signals (MESs). Brain magnetic resonance diffusion-weighted imaging (DWI) was performed before and after surgery.

RESULTS

There were 104 patients enrolled in the study. Eight patients developed ECA occlusion during surgery. The incidence of intraoperative ECA occlusion was significantly higher in patients without MESs at the phase of ECA and CCA declamping (8/12 [67%]) than in those with MESs (0/92 [0%]; P < .0001). Six patients exhibited new postoperative ischemic lesions on DWI. The incidence of intraoperative ECA occlusion (P < .0001) and the absence of MESs at declamping of the ECA and CCA while clamping the ICA (P <. 0001) were significantly higher in patients with development of new postoperative ischemic lesions on DWI than in those without. Sensitivity and specificity for the absence of MESs at declamping of the ECA and CCA while clamping the ICA for predicting development of new postoperative ischemic lesions on DWI were 100% (6/6) and 94% (92/98), respectively.

CONCLUSIONS

ECA occlusion at declamping of the ECA and CCA while clamping the ICA during CEA is a risk factor for development of new postoperative ischemic lesions. Intraoperative TCD monitoring accurately predicts the risk for development of such lesions.

Authors+Show Affiliations

Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan.Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan.Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan.Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan.Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan.Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan.Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan. Electronic address: kuogasa@iwate-med.ac.jp.

Pub Type(s)

Journal Article
Observational Study
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

29960793

Citation

Kobayashi, Masakazu, et al. "Impact of External Carotid Artery Occlusion at Declamping of the External and Common Carotid Arteries During Carotid Endarterectomy On Development of New Postoperative Ischemic Cerebral Lesions." Journal of Vascular Surgery, vol. 69, no. 2, 2019, pp. 454-461.
Kobayashi M, Yoshida K, Kojima D, et al. Impact of external carotid artery occlusion at declamping of the external and common carotid arteries during carotid endarterectomy on development of new postoperative ischemic cerebral lesions. J Vasc Surg. 2019;69(2):454-461.
Kobayashi, M., Yoshida, K., Kojima, D., Oshida, S., Fujiwara, S., Kubo, Y., & Ogasawara, K. (2019). Impact of external carotid artery occlusion at declamping of the external and common carotid arteries during carotid endarterectomy on development of new postoperative ischemic cerebral lesions. Journal of Vascular Surgery, 69(2), pp. 454-461. doi:10.1016/j.jvs.2018.03.437.
Kobayashi M, et al. Impact of External Carotid Artery Occlusion at Declamping of the External and Common Carotid Arteries During Carotid Endarterectomy On Development of New Postoperative Ischemic Cerebral Lesions. J Vasc Surg. 2019;69(2):454-461. PubMed PMID: 29960793.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Impact of external carotid artery occlusion at declamping of the external and common carotid arteries during carotid endarterectomy on development of new postoperative ischemic cerebral lesions. AU - Kobayashi,Masakazu, AU - Yoshida,Kenji, AU - Kojima,Daigo, AU - Oshida,Sotaro, AU - Fujiwara,Shunrou, AU - Kubo,Yoshitada, AU - Ogasawara,Kuniaki, Y1 - 2018/06/28/ PY - 2017/11/20/received PY - 2018/03/10/accepted PY - 2018/7/2/pubmed PY - 2019/4/23/medline PY - 2018/7/2/entrez KW - Carotid endarterectomy KW - Embolism KW - External carotid artery KW - Transcranial Doppler SP - 454 EP - 461 JF - Journal of vascular surgery JO - J. Vasc. Surg. VL - 69 IS - 2 N2 - OBJECTIVE: The external carotid artery (ECA) is inadvertently occluded during carotid endarterectomy (CEA). The importance of ECA occlusion has been emphasized as a loss of extracranial to intracranial collaterals, a source of chronic embolization, or a site for extended thrombosis during wound closure. This study aimed to determine whether ECA occlusion that inadvertently developed during endarterectomy and that was eventually detected using blood flow measurement of the ECA after declamping of all carotid arteries is a risk factor for development of new postoperative ischemic lesions at declamping of the ECA and common carotid artery (CCA) while clamping the internal carotid artery (ICA). This study also aimed to determine whether intraoperative transcranial Doppler (TCD) monitoring predicts the risk for development of such lesions. METHODS: This was a prospective observational study that included patients undergoing CEA for severe stenosis (≥70%) of the cervical ICA. When blood flow through the ECA measured using an electromagnetic flow meter decreased rapidly on clamping of only the ECA before carotid clamping for endarterectomy and was not changed by clamping of only the ECA after carotid declamping following endarterectomy, the patient was determined to have developed ECA occlusion. These patients underwent additional endarterectomy for the ECA. TCD monitoring in the ipsilateral middle cerebral artery was also performed throughout surgery to identify microembolic signals (MESs). Brain magnetic resonance diffusion-weighted imaging (DWI) was performed before and after surgery. RESULTS: There were 104 patients enrolled in the study. Eight patients developed ECA occlusion during surgery. The incidence of intraoperative ECA occlusion was significantly higher in patients without MESs at the phase of ECA and CCA declamping (8/12 [67%]) than in those with MESs (0/92 [0%]; P < .0001). Six patients exhibited new postoperative ischemic lesions on DWI. The incidence of intraoperative ECA occlusion (P < .0001) and the absence of MESs at declamping of the ECA and CCA while clamping the ICA (P <. 0001) were significantly higher in patients with development of new postoperative ischemic lesions on DWI than in those without. Sensitivity and specificity for the absence of MESs at declamping of the ECA and CCA while clamping the ICA for predicting development of new postoperative ischemic lesions on DWI were 100% (6/6) and 94% (92/98), respectively. CONCLUSIONS: ECA occlusion at declamping of the ECA and CCA while clamping the ICA during CEA is a risk factor for development of new postoperative ischemic lesions. Intraoperative TCD monitoring accurately predicts the risk for development of such lesions. SN - 1097-6809 UR - https://www.unboundmedicine.com/medline/citation/29960793/Impact_of_external_carotid_artery_occlusion_at_declamping_of_the_external_and_common_carotid_arteries_during_carotid_endarterectomy_on_development_of_new_postoperative_ischemic_cerebral_lesions_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0741-5214(18)31066-8 DB - PRIME DP - Unbound Medicine ER -