Abstract
This study analyzes the results of 457 carotid artery operations done in 416 patients by the same surgeon during a five-year period. A total of 27 central neurologic complications were observed, 14 were transient and 13 were permanent neurologic deficits, nine of which resulted in death. The causes of these accidents were: embolism (12), intolerance to clamping (7), carotid thrombosis (3), and reperfusion injury (2). In three cases no cause could be found. Preoperative predictive factors for these complications were analyzed statistically by multivariate analysis techniques. A high-risk group was identified, characterized by diffuse atherosclerotic disease and by the presence of a previous neurologic deficit. The prevention of neurologic complications in carotid surgery goes far beyond the controversy of whether or not a temporary inlying shunt should be used. In our opinion indications for shunting are limited. Neurologic complications can be prevented by maintaining awareness of certain temporary contraindications in patients with permanent neurologic deficits and by exacting operative techniques.
Resumen
La gravedad de la cirugía carotídea viene determinada por las complicaciones neurológiicas centrales que se presentan en el curso de estas intervenciones. Se han valorado 457 reconstrucciones carotídeas realizadas en 416 pacientes, por un solo cirujano durante un período de 4 años. La chnica preoperatoria permite hacer 4 grupos: asintomáticos 14%, sintomatología no hemisférica y/o vértebro-basilar (IVB) 22%, ataque isquémico transitorio (AIT) 45% y con déficits neurológicos el 19%. En el 23% había una estenosis carotídea contralateral y en el 5% una obliteración. Entre los factores de riesgo destacan la HTA, cardiopatía y arteriopatía de miembros inferiores. En el postoperatorio inmediato, se han presentado 14 déficits neurológicos sin secuela (3 %) y 13 ictus, de los cuales 9 han fallecido (cuadro II). Las causas han sido: 12 embolias, 7 isquemias durante el clampaje, 3 oclusiones postoperatorias y 2 revascularizaciones cerebrales. En cuanto a la correlación entre la clínica y los hallazgos angiográficos preoperatorios, sólo es significativo la existencia previa de una IVB, HTA o una cardiopatia. Siendo estos factores junto con la oclusión carotídea contralateral, los que determinan un mayor riesgo en los enfermos a los que se van a someter a cirugía carotídea. La técnica quirúrgica no modifica el pronóstico, no siendo pues valorable la utilización o no de shunt o de plastia, tampoco parece importante la realización de intervenciones combinadas. Los autores a la luz de estos resultados, concluyen que la causa de complicación neurológica en cirugía carotídea más importante son las embolias y la obliteración postoperatoria provocando más de la mitad de las complicaciones (15/27). Las provocadas por el clampaje, sólo representan el 25 % del total no pareciendo que la aplicación del shunt pueda resolver estos problemas. La conclusión es que, bajo el punto de vista pronóstico el grado de extensión de la arteriopatía puede ser el principal factor para la producción de complicaciones.
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Branchereau, A., Ondondong, F., Bordeaux, J. et al. Neurologic complications following carotid artery surgery: pathophysiology and predictive factors. Annals of Vascular Surgery 1, 79–85 (1986). https://doi.org/10.1007/BF02732460
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DOI: https://doi.org/10.1007/BF02732460