Key result
Intraoperative monitoring using rSO2, MEP, and SEP during carotid endarterectomy effectively guided selective internal shunting, resulting in zero perioperative ischemic complications.
Why the study?
Does intraoperative monitoring with rSO2, MEP, and SEP safely guide the indication for internal shunt placement during carotid endarterectomy?
Observational (n=12)
No
Does intraoperative monitoring with rSO2, MEP, and SEP safely guide the indication for internal shunt placement during carotid endarterectomy?
Intraoperative monitoring using rSO2, MEP, and SEP appears useful for determining the necessity of internal shunt placement during carotid endarterectomy to prevent ischemic complications.
Hypothesis-generating for multimodal monitoring to guide selective shunting in CEA; prospective trials needed before practice change.
To clarify the usefulness of intraoperative monitoring of regional saturation of oxygen (rSO2), motor evoked potential (MEP) and somatosensory evoked potential (SEP) for carotid endarterectomy (CEA) and indications for internal shunt, we analyzed the results of these monitoring modalities. Twelve consecutive patients (eight men, four women) underwent CEA from January 2010 to July 2013. The mean age of patients was 66.8 years (range, 47–81 years). Intraoperative monitoring of bilateral rSO2 using near-infrared spectroscopy (NIRS), bilateral transcranial MEP and ipsilateral SEP monitoring was conducted in all patients. The need for shunt placement was determined by a decrease in the rSO2 value of more than 20% or a decrease of more than 50% in amplitude of MEP or SEP. Six of the 12 patients underwent CEA with internal shunt. In this shunting group, five patients had ≧20% drop in rSO2, and ≧50% drop in MEP and SEP. In one patient who had no significant change in rSO2, MEP and SEP, internal shunt was inserted because she had a persistent primitive artery (proatlant artery type 2) from external carotid artery to vertebral artery and required arterectomy of the external carotid artery as well as internal carotid artery. The rSO2 values and amplitudes of MEP and SEP were unchanged in five out of the six patients who did not have contralateral ICA stenosis and underwent CEA without internal shunt. In one patient who did not have contralateral ICA stenosis, the rSO2 value could not be measured probably due to a giant frontal sinus. But because the amplitudes of MEP and SEP were unchanged during carotid clamping, the patient underwent CEA without internal shunt. No patients developed perioperative ischemic complications. Insertion of an internal shunt tube seems appropriate for patients in whom carotid clamping leads to a ≧20% reduction in ipsilateral rSO2 and a decrease in or disappearance of MEP and SEP amplitude. Insertion of an internal shunt tube appears to adequately restore these parameters.
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Koyama et al. (2014) conducted an observational in Carotid stenosis undergoing carotid endarterectomy (n=12). Intraoperative monitoring (rSO2, MEP, SEP) was evaluated on Perioperative ischemic complications. Intraoperative monitoring using rSO2, MEP, and SEP during carotid endarterectomy effectively guided selective internal shunting, resulting in zero perioperative ischemic complications.
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