Intraoperative Monitoring for Safe Carotid Endarterectomy in Patients with Internal Carotid Artery Stenosis

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  • 内頸動脈狭窄症に対する血栓内膜摘除術の術中モニタリング : 安全な手術のために

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To clarify the validity of intraoperative monitoring for preventing complications during carotid endarterctomy (CEA), we investigated the results of 151 CEA operations performed on 140 patients with significant stenosis of the internal carotid artery (ICA). The patients had a mean age of 63 years and a mean ICA stenosis of 64.7%. A T-shaped intraluminal shunt was used as a temporary bypass in each patient. We measured flow and stump pressure in the ICA, and recorded somatosensory evoked potential (SEP) from the ipsilateral parietal area. In 44 patients, oxyhemoglibin (HbO_2) at the ipsilateral frontal area was also monitored by near-infared spectroscopy. Surgery did not result in the death of any patient, but there were 12 (7.9%) instances of transient neurological deterioration and 4 (2.6%) operations resulted in permanent deficits. Patients with an ICA stenosis of ≩ 70% showed a significant decrease in ICA flow ; 3 of them showed a large increase in ICA flow after CEA and developed postoperative neurological deterioration, including 1 permanent deficit, probably due to postoperative hyperperfusion. Eight (25.0%) of 32 patients whose stump pressures were ≨30 mmHg demonstrated postoperative transient neurological deficits. Of 13 patients who showed a disappearance of N20/P25 in SEP, 7 (53.8%) demonstrated postoperative neurologic deterioration, including 1 patient with a permanent deficit. One (10%) of 10 patients who showed a significant decrease in HbO_2 developed a transient neurological deficit. We conclude that intraoperative monitoring was beneficial in terms of reducing operative complications. Monitoring of SEP was most sensitive for detection of cerebral ischemia. However, because SEP cannot provide information on the whole brain, a combination of monitoring methods is needed.

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