Carotid endoarterectomy in the presence of contralateral carotid occlusion.

BACKGROUND: The purpose of this study was to define a correct anesthesiological and surgical approach in patient who present a significant carotid stenosis with contralateral carotid occlusion.

METHODS: Between 1996 and 1998 in our Department of Vascular Surgery of the Hospital S. Giovanni Battista has been executed 337 Carotid Endoarterectomies (CEA). Of these, 44 patient (13%) had a contralateral internal carotid occlusion. Forty was male (91%), and 4 female (9%). Echo Doppler, angiography, angioTC or angio-RMN and TCD were performed in all patients. In all cases was executed a traditional CEA.

RESULTS: Because of the presence of a large ischaemic cerebral lesion or clamping intolerance 12 operation were performed under general anesthesia (27%). Shunt was used in 15 patients (34%) and patch was used in 10 cases (23%). In 2 cases (4.5%) there was be a thrombosis of the operated internal carotid artery and one patient died (2.3%).

CONCLUSIONS: The presence of contralateral internal carotid occlusion with carotid stenosis > 70% increase the risk of peroperative stroke because of the difficulty of collateral cerebral blood flow. The execution of echo Doppler, angiography, angioTC or angioRM and TCD and their evaluation permit to choice the best anesthesiological and surgical treatment. The utilization of narcosis with thiopental protection and shunting reducing the rate of perioperative stroke, but the local anesthesia allows the best monitoring of intraoperative cerebral function. This behaviour was correctly when in patient with contralateral internal carotid occlusion there is an insufficient intracranic vascularization or an extensive ischaemic lesion or clamping intolerance.