• Ali Bydon, Ajith J Thomas, Donald Seyfried, and Ghaus Malik.
• Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan 48202, USA.
• Surg Neurol. 2002 May 1;57(5):325-30; discussion 331-2.

BackgroundControversy about the optimal method of performing a carotid endarterectomy (CEA) exists despite its widespread application and support from various randomized clinical trials. Many surgeons selectively or routinely use electroencephalography (EEG) monitoring as well as shunting when performing this operation.MethodsWe conducted this retrospective study to assess the maximum carotid clamp time without shunting or EEG monitoring during a CEA without the development of neurological deficits in an already compromised cerebral circulation.ResultsFifteen consecutive patients who underwent CEAs between 1988 and 1999 met our criteria of angiographically documented ipsilateral internal carotid artery (ICA) stenosis with contralateral ICA occlusion. The patient presentations included asymptomatic (14%), transient ischemic attack (TIA) (50%), and stroke (36%). All patients were operated under general anesthesia without shunting and only 4 patients underwent EEG monitoring. On angiography, all 15 patients had ipsilateral ICA stenosis (70-99%) and contralateral occlusion. In 54% of patients, the vertebral arteries (VAs) were both patent, while in 46% of patients only 1 VA was patent. Eighty-five percent of patients had at least 1 patent anterior communicating (Pcomm) artery, while 15% had nonvisualized Pcomm arteries bilaterally. Of the 15 patients, 14 had a patent anterior communicating artery. The mean clamp time of the CCA was 18.5 minutes (range 14-30 minutes). None of the 15 patients had new neurological changes immediately postoperatively or during the 6 weeks of follow-up.ConclusionWe propose that shunting may not be necessary during CEA for high-grade stenosis with contralateral ICA occlusion, presumably because of adequate distal small vessel collaterals.

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