IYSC10 - Determinants of Shunt Use in Symptomatic Patients Undergoing Carotid Endarterectomy with Awake Cerebral Protection and Neurological Monitoring

Objectives: This retrospective study aimed to evaluate factors influencing shunt utilization in a cohort of patients undergoing carotid endarterectomy (CEA) with conscious awake cerebral protection (COPAGEA) and clinical monitoring of neurological status for symptomatic carotid stenosis in a single high-volume surgical center.

Methods: Between January 2014 and December 2020, 1369 consecutive CEA procedures were performed at our institution. Data related to these procedures were prospectively collected in a dedicated database, including preoperative assessment, surgical details, perioperative outcomes and long-term follow-up. Among the 213 cases performed in symptomatic patients, 29, operated under general anesthesia with routine shunt use, were excluded. The study group included 184 patients operated with COPAGEA and selective shunt use. The shunt insertion rate was assessed, and binary logistic regression analysis was conducted to identify demographic, clinical, anatomical, and technical factors independently associated with shunt use. Perioperative outcomes, including mortality, major neurological events, and major local and systemic complications, were also evaluated.

Results: The shunt insertion rate was 16.3%. This rate was similar between patients with stable neurological status (isolated TIA occurring more than 48 hours before surgery or stabilized major stroke, 15.7%) and neurologically unstable patients (recent/progressing TIA, crescendo TIA, acute minor stroke, 18.1%). Clinical scenarios most associated with shunt requirement were isolated TIA (21.5%) and acute minor stroke (29.5%). No differences were identified in the shunt insertion rate based on the timing of surgery relative to the clinical event. However, among patients with isolated TIA, shunt use was unnecessary in cases operated within 48 hours, compared to 30% for surgery between 3 and 7 days, and 14.5% for surgery beyond 7 days post-TIA. Multivariate analysis demonstrated that only the presence of contralateral carotid occlusion was independently associated with an increased need for shunt insertion (p < 0.001, HR 4.5, 95% CI 1.7-6.6). The overall 30-day stroke and death rate was 1.1% (2 cases of perioperative stroke in stable patients operated for isolated TIA, with one case involving intraoperative shunt use). The rate of non-fatal major local and systemic complications was 4.3%.

Conclusions: Clinical monitoring during COPAGEA lowered the need for intraluminal shunt use in patients undergoing surgery for symptomatic carotid stenosis, regardless of stable or unstable neurological status. In patients with isolated TIA, performing the procedure within 48 hours completely eliminated the need for shunt use. Regardless of clinical presentation and surgery timing, the rate of perioperative complications remained significantly lower than that recommended by guidelines