Key result
Early sequential clamping with ICG mapping linked to ~82% lower odds of postoperative DWI lesions.
Why the study?
The study aimed to describe a standardized early clamping technique combining pre-ischemic indocyanine green plaque mapping with sequential proximal occlusion during carotid endarterectomy and assess its association with silent cerebral ischemia and preliminary resident experience.
Does standardized early sequential clamping with pre-ischemic indocyanine green plaque mapping reduce new ipsilateral postoperative diffusion-weighted imaging lesions compared to the conventional technique in patients undergoing carotid endarterectomy?
Cohort (n=66)
No
Does standardized early sequential clamping with pre-ischemic indocyanine green plaque mapping reduce new ipsilateral postoperative diffusion-weighted imaging lesions compared to the conventional technique in patients undergoing carotid endarterectomy?
Standardized early sequential clamping with pre-ischemic indocyanine green plaque mapping during carotid endarterectomy was associated with a lower incidence of silent postoperative cerebral ischemia on diffusion-weighted imaging compared to conventional technique.
Answers are grounded in this paper and cite their sources.
May support standardized clamping to limit silent ischemia in endarterectomy; leaves open need for randomized confirmation before adoption.
OBJECTIVE We describe a standardized early clamping technique combining pre-ischemic indocyanine green (ICG) plaque mapping with sequential proximal occlusion during carotid endarterectomy (CEA) and assess its association with silent cerebral ischemia and preliminary resident experience. METHODS We conducted a single-center, retrospective before-after cohort study of patients undergoing CEA for cervical internal carotid artery (ICA) stenosis between 2020 and 2025. We assigned patients by each period's standard-of-care technique: conventional method (2020-2022; n = 35) and early clamping method (2023-2025; n = 31). In the early clamping method, we opened only the superficial carotid sheath, mapped the plaque and set the distal clamp landmark by ICG before flow arrest, and clamped the superior thyroid, external carotid, and common carotid arteries before dissecting the distal ICA. The primary outcome was new ipsilateral postoperative diffusion-weighted imaging (DWI) lesions within 3 days. We used Firth penalized logistic regression with one covariate per model (exploratory); a predefined subgroup compared attendings (n = 9) and senior residents (n = 22). RESULTS New DWI lesions occurred in 1/31 (3.2%) early versus 7/35 (20.0%) conventional cases (P = .037). Early clamping remained associated with fewer lesions after adjustment for unstable plaque (adjusted OR, 0.18; 95% CI, 0.02-0.90) and for symptomatic presentation (OR, 0.18; 95% CI, 0.02-0.91). Among early-clamping cases, lesions occurred in 1/22 residents (4.6%) and 0/9 attendings (P = .516), with no symptomatic infarction. CONCLUSION Early sequential clamping with pre-ischemic ICG mapping was associated with less silent cerebral ischemia after CEA. Because technique and era were inseparable, this association is hypothesis-generating and warrants a prospective, multicenter, controlled study.
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Uchimura et al. (2026) conducted a cohort in Cervical internal carotid artery (ICA) stenosis (n=66). Standardized early sequential clamping with pre-ischemic indocyanine green (ICG) plaque mapping vs. Conventional carotid endarterectomy method was evaluated on New ipsilateral postoperative diffusion-weighted imaging (DWI) lesions within 3 days (OR 0.18, 95% CI 0.02-0.90, p=0.037). Early sequential clamping with pre-ischemic ICG mapping was associated with fewer new postoperative DWI lesions compared to conventional CEA (3.2% vs 20.0%; P=.037).
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