Immediate conversion to CAS after neurological intolerance at cross-clamping test during CEA: a preliminary experience.

Aim: The aim of this preliminary study is to evaluate the feasibility and efficacy of CAS as treatment option to endarterectomy when carotid shunt cannot be used safely.
Methods: The medical records concerning 469 carotid stenosis treated between January 2006 and December 2009 were retrospectively reviewed, focusing on cross-clamp intolerance during CEA. Patients with cross-clamping intolerance were divided in two groups. Group 1: those that concluded the open procedure with the use of a shunt, and Group 2: those who experience immediate brain intolerance and coma and were immediately converted to an endovascular procedure. Mortality and neurological adverse event rate were compared between shunted CEA and cross-clamping intolerant cases converted into CAS. The secondary end-point was long-term survival.
Results: Carotid cross-clamp intolerance occurred in 30 cases (8.7%). CEA with Pruitt-Inahara's shunt was performed in 17 cases with a perioperative neurological adverse event rate of 23.5%. In 13 cases limitations to shunting due to quick onset of coma and/or an unfavorable anatomy were encountered. In these 13 cases the open intervention was immediately converted into endovascular procedure. Technical success was achieved in all the converted to CAS cases (100%), with a perioperative neurological adverse event rate of 7.7% (P=0.35 between the two groups). No significant difference emerges comparing patient's survival between the cases
Conclusion: Nevertheless, the small dimension of this survey, immediate conversion to CAS resulted feasible with a lower risk of neurological adverse events if compared to CEA with shunt, and could be considered as an alternative to CEA when carotid shunt cannot be used safely.