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Journal of Peking University (Health Sciences) ›› 2021, Vol. 53 ›› Issue (6): 1144-1151. doi: 10.19723/j.issn.1671-167X.2021.06.023

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Effect of different shunt strategies on cerebral infarction after carotid endarterectomy

BAI Peng1,WANG Tao2,ZHOU Yang1,TAO Li-yuan3,LI Gang1,LI Zheng-qian1,GUO Xiang-yang1,△()   

  1. 1. Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China
    2. Department of Neurosurgery, Peking University Third Hospital, Beijing 100191, China
    3. Clinical Epidemiology Research Center, Peking University Third Hospital, Beijing 100191, China
  • Received:2020-06-04 Online:2021-12-18 Published:2021-12-13
  • Contact: Xiang-yang GUO E-mail:puthmzk@hsc.pku.edu.cn
  • Supported by:
    Beijing Natural Science Foundation(7172230)

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Abstract:

Objective: The key point of anesthesia management in carotid endarterectomy (CEA) is to maintain adequate cerebral perfusion during carotid artery occlusion. Placement of shunt is one of the common surgical methods. This study analyzed the effects of different shunt strategies on cerebral infarction after carotid endarterectomy. Methods: A total of 443 patients who underwent CEA under general anesthesia within 2 years were divided into imaging group (based on preoperative imaging data as the basis for shunt) and stump pressure group (based on intraoperative stump pressure as the basis for shunt). The preoperative demographic data, past medical history, degree of cervical vascular stenosis, blood pressure at each time point during the perioperative period, vascular blocking time, whether to place the shunt, postoperative hospital stay, cerebral infarction during hospitalization, and other adverse events were collected and compared between the two groups. On this basis, the preoperative and intraoperative conditions with significant differences were matched with propensity scores, and the influence of different shunt strategies on postoperative cerebral infarction was analyzed. Results: In the study, 268 patients in the imaging group and 175 patients in the stump pressure group underwent CEA under general anesthesia. There were statistically significant differences in basic conditions and blood pressure at each time point between the two groups. After matching the propensity scores, 105 patients in each of the two groups were matched. The basic conditions of the patients before surgery and the difference in blood pressure of the two groups at each time point were not statistically significant. There was no significant diffe-rence in the incidence of postoperative cerebral infarction between the two groups (1.9% vs. 1.0%, P>0.999). The intraoperative shunt rate in the imaging group was lower than that in the stump pressure group (0 vs. 22.9%, P<0.001). The postoperative hospital stay in the imaging group was 8 (7, 8) days, which was longer than the stump pressure group 5 (4, 6) days (P<0.001). Conclusion: The rate of the shunt was lower according to preoperative imaging examination than that according to the residual pressure in our hospital. There is no significant difference in the incidence of cerebral infarction during the postoperative hospital stay. The effect of different shunt strategies on cerebral infarction needs further study.

Key words: Carotid endarterectomy, Cerebral infarction, Cerebrovascular circulation, Carotid stenosis

CLC Number: 

  • R651.12

Figure 1

The flow chart of different shunt strategies CEA, carotid endarterectomy; CABG, coronary artery bypass grafting."

Table 1

Preoperative basic data of the two groups"

Items Imaging group (n=268) Stump pressure group (n=175) t/χ2 P value
Gender (male/female) 219 (81.7%)/49 (18.3%) 132 (75.4%)/43 (24.6%) 2.544 0.111
Age/years 65.0 (60.0, 71.0) 68.0 (62.0, 75.0) 6.814 0.009
BMI/(kg/m2) 24.5 (22.6, 26.9) 25.1 (22.9, 27.4) 1.738 0.187
Hypertension 198 (73.9%) 128 (73.1%) 0.030 0.863
Diabetes 89 (33.2%) 68 (38.9%) 1.476 0.224
Coronary heart disease 76 (28.4%) 57 (32.6%) 0.895 0.344
Preoperative neurological symptoms 0.699 0.403
Yes (cerebral infarction/TIA) 138 (51.5%)
[82 (30.6%)/56 (20.9%)]		 83 (47.4%)
[66 (37.7%)/17 (9.7%)]
No 130 (48.5%) 92 (52.6%)
Carotid artery stenosis on the operative side 47.810 <0.001
Light 0 (0) 5 (2.9%)
Moderate 10 (3.7%) 40 (22.9%)
Severe 258 (96.3%) 130 (74.3%)
Carotid artery stenosis on the other side 7.147 0.028
Light 156 (58.2%) 119 (68.0%)
Moderate 52 (19.4%) 34 (19.4%)
Severe 60 (22.4%) 22 (12.6%)
Vertebral artery stenosis on the operative side 2.346 0.309
Light 220 (82.1%) 153 (87.4%)
Moderate 17 (6.3%) 7 (4.0%)
Severe 31 (11.6%) 15 (8.8%)
Vertebral artery stenosis on the operative side 1.150 0.563
Light 222 (82.8%) 150 (85.7%)
Moderate 18 (6.7%) 12 (6.9%)
Severe 28 (10.4%) 13 (7.4%)

Table 2

Blood pressure, shunt and blocking time of the two groups"

Items Imaging group (n=268) Stump pressure group (n=175) t/χ2 P value
T1 SBP/mmHg 130 (130, 140) 133 (127, 142) 6.523 0.011
T1 DBP/mmHg 75 (70, 80) 74 (68, 80) 6.219 0.013
T1 MBP/mmHg 93 (90, 97) 93 (89, 99) 0.164 0.685
T2 SBP/mmHg 160 (145, 165) 156 (145, 169) 0.694 0.405
T2 DBP/mmHg 80 (70, 85) 79 (71, 86) 0.045 0.831
T2 MBP/mmHg 105 (97, 112) 105 (98, 113) 0.344 0.563
T3 SBP/mmHg 130 (120, 149) 138 (126, 147) 5.645 0.018
T3 DBP/mmHg 65 (60, 70) 65 (58, 73) 0.005 0.946
T3 MBP/mmHg 87 (82, 97) 90 (83, 98) 1.187 0.276
T4 SBP/mmHg 157±14 156±18 0.900 0.369
T4 standard deviation of SBP/mmHg 5 (3, 8) 5 (2, 7) 3.113 0.078
T4 DBP/mmHg 72±10 70±11 1.850 0.065
T4 standard deviation of DBP/mmHg 3 (2, 4) 3 (1, 5) 0.080 0.777
T4 MBP/mmHg 101±9 99±11 1.787 0.075
T5 SBP/mmHg 130 (120, 140) 130 (121, 139) 3.378 0.066
T5 DBP/mmHg 65 (60, 70) 60 (55, 67) 9.289 0.002
T5 MBP/mmHg 87 (80, 93) 84 (78, 90) 9.557 0.002
T6 SBP/mmHg 140 (130, 140) 133 (122, 142) 11.762 0.001
T6 DBP/mmHg 75 (70, 80) 70 (65, 76) 51.968 <0.001
T6 MBP/mmHg 97 (93, 100) 92 (86, 97) 45.535 <0.001
Blocking time/min 25.0 (25.0, 29.0) 35.0 (23.0, 42.0) 16.197 <0.001
Shunt 14 (5.2%) 32 (18.3%) 19.410 <0.001

Table 3

Postoperative adverse events and hospital stay of the two groups"

Items Imaging group (n=268) Stump pressure group (n=175) t/χ2 P value
Cerebral infarction 5 (1.9%) 1 (0.6%) 1.327 0.410
Cerebral hemorrhage 3 (1.1%) 0 (0) 1.972 0.281
Myocardial ischemia and myocardial infarction 6 (2.2%) 1 (0.6%) 1.893 0.253
Atrial fibrillation (new onset) 2 (0.7%) 1 (0.6%) 0.048 >0.999
Pulmonary infection and respiratory failure 1 (0.4%) 0 (0) 0.654 >0.999
Wound infection 0 (0) 1 (0.6%) 1.535 0.395
Postoperative hospital stay/d 8 (7, 8) 5 (5, 6) 67.918 <0.001

Table 4

Preoperative basic data after propensity score matching of the two groups"

Items Imaging group (n=105) Stump pressure group (n=105) t/χ2 P value
Gender (male/female) 77 (73.3%)/28 (26.7%) 78 (74.3%)/27 (25.7%) 0.025 0.875
Age/years 66.0 (62.0, 72.0) 66.0 (61.0, 74.5) 0.011 0.918
BMI/(kg/m2) 24.4 (22.5, 27.1) 24.9 (22.3, 27.1) 0.284 0.594
Hypertension 81 (77.1%) 82 (78.1%) 0.027 0.868
Diabetes 41 (39.0%) 43 (41.0%) 0.079 0.778
Coronary heart disease 26 (24.8%) 35 (33.3%) 1.871 0.171
Preoperative neurological symptoms 0.019 0.890
Yes (cerebral infarction/TIA) 52 (49.5%)
[29 (27.6%)/23 (21.9%)]		 53 (50.5%)
[44 (41.9%)/9 (8.6%)]
No 53 (50.5%) 52 (49.5%)
Carotid artery stenosis on the operative side 0.000 >0.999
Light 0 (0) 0 (0)
Moderate 8 (7.6%) 8 (7.6%)
Severe 97 (92.4%) 97 (92.4%)
Carotid artery stenosis on the other side 0.029 0.986
Light 68 (64.8%) 67 (63.8%)
Moderate 23 (21.9%) 24 (22.9%)
Severe 14 (13.3%) 14 (13.3%)
Vertebral artery stenosis on the operative side 1.593 0.451
Light 220 (82.1%) 153 (87.4%)
Moderate 17 (6.3%) 7 (4.0%)
Severe 31 (11.6%) 15 (8.8%)
Vertebral artery stenosis on the operative side 2.339 0.311
Light 87 (82.9%) 93 (88.6%)
Moderate 9 (8.6%) 5 (4.8%)
Severe 9 (8.6%) 7 (6.7%)

Table 5

Blood pressure, shunt and blocking time after propensity score matching of the two groups"

Items Imaging group (n=105) Stump pressure group (n=105) t/χ2 P value
T1 SBP/mmHg 130 (130, 140) 133 (128, 142) 0.150 0.699
T1 DBP/mmHg 75 (70, 80) 75 (70, 80) 0.320 0.571
T1 MBP/mmHg 93 (90, 98) 93 (90, 100) 0.805 0.370
T2 SBP/mmHg 155 (140, 170) 157 (145, 170) 0.690 0.406
T2 DBP/mmHg 80 (70, 85) 80 (71, 86) 0.366 0.545
T2 MBP/mmHg 103 (96, 113) 106 (98, 112) 0.977 0.323
T3 SBP/mmHg 135 (130, 150) 138 (127, 146) 0.276 0.606
T3 DBP/mmHg 65 (60, 70) 66 (58, 74) 0.023 0.879
T3 MBP/mmHg 90 (83, 97) 90 (82, 98) 0.009 0.925
T4 SBP/mmHg 156±13 156±17 0.150 0.881
T4 standard deviation of SBP/mmHg 5 (4, 8) 5 (2, 7) 8.584 0.003
T4 DBP/mmHg 70±11 70±11 0.160 0.873
T4 standard deviation of DBP/mmHg 3 (2, 4) 2 (1, 4) 6.424 0.011
T4 MBP/mmHg 99±9 99±11 0.187 0.852
T5 SBP/mmHg 130 (120, 140) 130 (121, 140) 0.016 0.899
T5 DBP/mmHg 60 (55, 70) 60 (55, 68) 0.148 0.700
T5 MBP/mmHg 83 (80, 90) 84 (78, 90) 0.029 0.865
T6 SBP/mmHg 135 (130, 140) 133 (127, 145) 0.057 0.812
T6 DBP (mmHg) 75 (70, 80) 72 (68, 79) 0.943 0.331
T6 MBP/mmHg 95 (90, 100) 94 (89, 99) 0.687 0.407
Blocking time/min 25.0 (25.0, 30.0) 30.0 (20.0, 40.0) 1.659 0.198
Shunt 0 (0) 24 (22.9%) 27.097 <0.001

Table 6

Postoperative adverse events and hospital stay after propensity score matching of the two groups"

Items Imaging group (n=105) Stump pressure group (n=105) t/χ2 P value
Cerebral infarction 2 (1.9%) 1 (1.0%) 0.338 >0.999
Cerebral hemorrhage 2 (1.9%) 0 (0) 2.019 0.498
Myocardial ischemia and myocardial infarction 1 (1.0%) 1 (1.0%) 0.000 >0.999
Atrial fibrillation (new onset) 0 (0) 1 (1.0%) 1.005 >0.999
Pulmonary infection and respiratory failure 0 (0) 0 (0)
Wound infection 0 (0) 0 (0)
Postoperative hospital stay/d 8 (7, 8) 5 (4, 6) 56.452 <0.001
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