Propensity-matched comparison of proximal versus distal shunt insertion during eversion carotid endarterectomy of the internal carotid artery in symptomatic and asymptomatic patients.

Abstract

Objective: The aim of this study was to compare the two intraoperative shunting techniques (proximal vs. distal) during eversion endarterectomy (EEA) of the internal carotid artery (ICA).

Methods: All patients operated between January 2011 and December 2022 who received routine shunting of the ICA were enrolled in this retrospective study. Patients undergoing selective shunting, patch angioplasty of the ICA, redo surgeries or surgery performed by a resident were excluded. Intraoperative shunt placement took place after completing the eversion of the ICA. The Patients were divided into two groups based on shunt placement technique: (i) distal shunting, where the shunt was firstly inserted into the ICA and then into the CCA, and (ii) proximal shunting, where the shunt was firstly inserted into the common carotid artery (CCA) and then into the ICA. Propensity score matching was used to compare the two groups. All procedures were performed under general anesthesia, with regional cerebral oxygenation monitoring. The primary endpoint was the incidence of perioperative stroke and in-hospital mortality.

Results: A total of 658 thrombendarteriectomies of the ICA using intraoperative shunt were performed during the study period. Proximal shunting was used in n=330 (50.2%) and distal shunting in n=328 (49.8%). Using the Propensity score matching 260 pairs were generated for analysis. The perioperative stroke rate was significantly higher in the proximal shunting group n=13(5%), compared to the distal shunting group n=4 (1.5%), (p<0.05). The overall in-hospital mortality incidence was 0.6% (n=3) (n= 2 in the proximal shunting group and n=1 in the distal shunting group (p=0.99).

Conclusion: In the setting of an elective shunting of the ICA during eversion endarterectomy, proximal first placement of the shunt may cause a higher incidence of perioperative stroke compared to distal first placement of the stunt. A distal first shunting strategy seems reasonable when performing EEA surgery to improve patient outcomes.