Carotid endarterectomy without a shunt for symptomatic lesions associated with contralateral severe stenosis or occlusion

Purpose: The purpose of this study was to assess the adequacy of thiopental protection against ischemic cerebral damage in patients undergoing carotid endarterectomy for symptomatic stenosis greater than 70% in association with contralateral stenosis greater than 70% or contralateral occlusion. Methods: All patients (n = 259) with severe bilateral carotid disease who underwent carotid endarterectomy for symptomatic stenosis greater than 70% were extracted from the database of an ongoing prospective carotid surgery study. Large-dose thiopental sodium without shunting was used for cerebral protection during endarterectomy. Asymmetric electroencephalogram changes during the operation, carotid occlusion time, stroke onset, and neuropathologic outcomes were analyzed. Results: Three contralateral strokes occurred in the series, producing a cerebral morbidity/mortality rate of 1.2% (major 0.4%, minor 0.8%). Transient morbidity was 1.9% made up of two reversible ischemic neurologic deficits and three transient ischemic attacks. New asymmetric electroencephalography changes were seen in 49 (19%) patients, one of whom had transient deficit. Average occlusion time was 35 minutes. All strokes occurred within 24 hours of the procedure. Patients with previous stroke and systemic hypertension seemed at greatest risk, and the contralateral hemisphere was the area at greatest risk. All transient deficits were ipsilateral and related to technical complications rather than failed protection. Conclusions: Thiopental cerebral protection eliminates strokes caused by complications of shunting, prevents ischemic stroke during carotid occlusion for periods up to 67 minutes (average 35 minutes), allows meticulous management of the operative site, may modify or minimize clinical neurologic deficit, and in our experience has rendered intraluminal shunting obsolete.