Incomplete circle of Willis is associated with a higher incidence of neurologic events during carotid eversion endarterectomy without shunting

Péter Vince Banga, Andrea Varga, Csaba Csobay-Novák, Márton Kolossváry, Emese Szántó, Gustavo Oderich, László Entz, Péter Sótonyi

Research output: Contribution to journalArticle

2 Citations (Scopus)

Abstract

Objective: A complete circle of Willis (CoW) is considered an important collateral network to maintain blood flow during cross-clamping in carotid endarterectomy (CEA). The aim of this study was to evaluate the impact of an incomplete CoW with isolated middle cerebral artery (iMCA) on immediate neurologic events (INEs) after CEA. Methods: We prospectively collected the clinical data and outcomes of 902 patients who underwent CEA under general anesthesia between 2013 and 2015. All patients had preoperative computed tomography angiography of the extracranial and intracranial cerebral circulation. Indications were asymptomatic (52%) and symptomatic (48%) carotid artery disease. Patients who had CEA with shunt (n = 35) and those with inadequate intracranial imaging to assess CoW were excluded (n = 322) only. Computed tomography angiography images were reviewed retrospectively and independently by two vascular radiologists who were blinded for treatment outcomes. Imaging assessment included the vertebral and carotid circulation and each segment of the CoW, which was classified as normal, hypoplastic (diameter < 0.8 mm) or absent. The ipsilateral MCA was considered isolated if there was an absence of the anterior and posterior communicating branches from the contralateral carotid or posterior circulations. INE was defined as any transient ischemic attack (TIA) and stroke diagnosed immediately after the procedure. Results: Of the 545 included patients (331 males; mean age, 69 ± 8 years), 12 (2.2%) had a stroke in the postoperative period. There were 20 INEs (8 strokes and 12 TIAs). A complete CoW was rare; it was only detected in 19 patients (3.5%) and an iMCA was found in 34 patients (6.3%). When at least one collateral circulation was complete (in 330 patients), we observed only four INEs (1.2%). Of the 34 patients with an iMCA, 8 (24%) had INE (6 TIAs and 2 strokes). Overall, iMCA was an independent predictor of INEs (odds ratio, 11.12; 95% confidence interval, 3.57-35.87; P < .001). With logistic regression, the model included hypertension, smoking, diabetes, hyperlipidemia, carotid clamping time (minutes), contralateral significant internal carotid artery stenosis of greater than 90%, ipsilateral significant internal carotid artery stenosis of greater than 90%, preoperative symptoms in 6 months, and iMCA; above iMCA only symptomatic patients had significant risk (odds ratio, 3.34; 95% confidence interval, 1.19-9.73; P = .02), whereas all other parameters were not significant. Conclusions: An iMCA carries more than a 10-fold higher the risk of INEs after CEA with cross-clamping without shunt protection. In these patients, routine shunting is recommended to prevent INEs.

Original languageEnglish (US)
JournalJournal of Vascular Surgery
DOIs
StateAccepted/In press - Jan 1 2018

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Circle of Willis
Carotid Endarterectomy
Nervous System
Middle Cerebral Artery
Incidence
Stroke
Constriction
Carotid Stenosis
Odds Ratio
Cerebrovascular Circulation
Confidence Intervals
Collateral Circulation
Carotid Artery Diseases
Transient Ischemic Attack
Hyperlipidemias
Postoperative Period
General Anesthesia
Blood Vessels
Logistic Models
Smoking

Keywords

  • Carotid endarterectomy
  • Cerebral circulation
  • Circle of Willis
  • Collateral circulation
  • Computed tomography angiography
  • Middle cerebral artery
  • Selective shunting
  • Stroke

ASJC Scopus subject areas

  • Surgery
  • Cardiology and Cardiovascular Medicine

Cite this

Incomplete circle of Willis is associated with a higher incidence of neurologic events during carotid eversion endarterectomy without shunting. / Banga, Péter Vince; Varga, Andrea; Csobay-Novák, Csaba; Kolossváry, Márton; Szántó, Emese; Oderich, Gustavo; Entz, László; Sótonyi, Péter.

In: Journal of Vascular Surgery, 01.01.2018.

Research output: Contribution to journalArticle

Banga, Péter Vince ; Varga, Andrea ; Csobay-Novák, Csaba ; Kolossváry, Márton ; Szántó, Emese ; Oderich, Gustavo ; Entz, László ; Sótonyi, Péter. / Incomplete circle of Willis is associated with a higher incidence of neurologic events during carotid eversion endarterectomy without shunting. In: Journal of Vascular Surgery. 2018.
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title = "Incomplete circle of Willis is associated with a higher incidence of neurologic events during carotid eversion endarterectomy without shunting",
abstract = "Objective: A complete circle of Willis (CoW) is considered an important collateral network to maintain blood flow during cross-clamping in carotid endarterectomy (CEA). The aim of this study was to evaluate the impact of an incomplete CoW with isolated middle cerebral artery (iMCA) on immediate neurologic events (INEs) after CEA. Methods: We prospectively collected the clinical data and outcomes of 902 patients who underwent CEA under general anesthesia between 2013 and 2015. All patients had preoperative computed tomography angiography of the extracranial and intracranial cerebral circulation. Indications were asymptomatic (52{\%}) and symptomatic (48{\%}) carotid artery disease. Patients who had CEA with shunt (n = 35) and those with inadequate intracranial imaging to assess CoW were excluded (n = 322) only. Computed tomography angiography images were reviewed retrospectively and independently by two vascular radiologists who were blinded for treatment outcomes. Imaging assessment included the vertebral and carotid circulation and each segment of the CoW, which was classified as normal, hypoplastic (diameter < 0.8 mm) or absent. The ipsilateral MCA was considered isolated if there was an absence of the anterior and posterior communicating branches from the contralateral carotid or posterior circulations. INE was defined as any transient ischemic attack (TIA) and stroke diagnosed immediately after the procedure. Results: Of the 545 included patients (331 males; mean age, 69 ± 8 years), 12 (2.2{\%}) had a stroke in the postoperative period. There were 20 INEs (8 strokes and 12 TIAs). A complete CoW was rare; it was only detected in 19 patients (3.5{\%}) and an iMCA was found in 34 patients (6.3{\%}). When at least one collateral circulation was complete (in 330 patients), we observed only four INEs (1.2{\%}). Of the 34 patients with an iMCA, 8 (24{\%}) had INE (6 TIAs and 2 strokes). Overall, iMCA was an independent predictor of INEs (odds ratio, 11.12; 95{\%} confidence interval, 3.57-35.87; P < .001). With logistic regression, the model included hypertension, smoking, diabetes, hyperlipidemia, carotid clamping time (minutes), contralateral significant internal carotid artery stenosis of greater than 90{\%}, ipsilateral significant internal carotid artery stenosis of greater than 90{\%}, preoperative symptoms in 6 months, and iMCA; above iMCA only symptomatic patients had significant risk (odds ratio, 3.34; 95{\%} confidence interval, 1.19-9.73; P = .02), whereas all other parameters were not significant. Conclusions: An iMCA carries more than a 10-fold higher the risk of INEs after CEA with cross-clamping without shunt protection. In these patients, routine shunting is recommended to prevent INEs.",
keywords = "Carotid endarterectomy, Cerebral circulation, Circle of Willis, Collateral circulation, Computed tomography angiography, Middle cerebral artery, Selective shunting, Stroke",
author = "Banga, {P{\'e}ter Vince} and Andrea Varga and Csaba Csobay-Nov{\'a}k and M{\'a}rton Kolossv{\'a}ry and Emese Sz{\'a}nt{\'o} and Gustavo Oderich and L{\'a}szl{\'o} Entz and P{\'e}ter S{\'o}tonyi",
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language = "English (US)",
journal = "Journal of Vascular Surgery",
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TY - JOUR

T1 - Incomplete circle of Willis is associated with a higher incidence of neurologic events during carotid eversion endarterectomy without shunting

AU - Banga, Péter Vince

AU - Varga, Andrea

AU - Csobay-Novák, Csaba

AU - Kolossváry, Márton

AU - Szántó, Emese

AU - Oderich, Gustavo

AU - Entz, László

AU - Sótonyi, Péter

PY - 2018/1/1

Y1 - 2018/1/1

N2 - Objective: A complete circle of Willis (CoW) is considered an important collateral network to maintain blood flow during cross-clamping in carotid endarterectomy (CEA). The aim of this study was to evaluate the impact of an incomplete CoW with isolated middle cerebral artery (iMCA) on immediate neurologic events (INEs) after CEA. Methods: We prospectively collected the clinical data and outcomes of 902 patients who underwent CEA under general anesthesia between 2013 and 2015. All patients had preoperative computed tomography angiography of the extracranial and intracranial cerebral circulation. Indications were asymptomatic (52%) and symptomatic (48%) carotid artery disease. Patients who had CEA with shunt (n = 35) and those with inadequate intracranial imaging to assess CoW were excluded (n = 322) only. Computed tomography angiography images were reviewed retrospectively and independently by two vascular radiologists who were blinded for treatment outcomes. Imaging assessment included the vertebral and carotid circulation and each segment of the CoW, which was classified as normal, hypoplastic (diameter < 0.8 mm) or absent. The ipsilateral MCA was considered isolated if there was an absence of the anterior and posterior communicating branches from the contralateral carotid or posterior circulations. INE was defined as any transient ischemic attack (TIA) and stroke diagnosed immediately after the procedure. Results: Of the 545 included patients (331 males; mean age, 69 ± 8 years), 12 (2.2%) had a stroke in the postoperative period. There were 20 INEs (8 strokes and 12 TIAs). A complete CoW was rare; it was only detected in 19 patients (3.5%) and an iMCA was found in 34 patients (6.3%). When at least one collateral circulation was complete (in 330 patients), we observed only four INEs (1.2%). Of the 34 patients with an iMCA, 8 (24%) had INE (6 TIAs and 2 strokes). Overall, iMCA was an independent predictor of INEs (odds ratio, 11.12; 95% confidence interval, 3.57-35.87; P < .001). With logistic regression, the model included hypertension, smoking, diabetes, hyperlipidemia, carotid clamping time (minutes), contralateral significant internal carotid artery stenosis of greater than 90%, ipsilateral significant internal carotid artery stenosis of greater than 90%, preoperative symptoms in 6 months, and iMCA; above iMCA only symptomatic patients had significant risk (odds ratio, 3.34; 95% confidence interval, 1.19-9.73; P = .02), whereas all other parameters were not significant. Conclusions: An iMCA carries more than a 10-fold higher the risk of INEs after CEA with cross-clamping without shunt protection. In these patients, routine shunting is recommended to prevent INEs.

AB - Objective: A complete circle of Willis (CoW) is considered an important collateral network to maintain blood flow during cross-clamping in carotid endarterectomy (CEA). The aim of this study was to evaluate the impact of an incomplete CoW with isolated middle cerebral artery (iMCA) on immediate neurologic events (INEs) after CEA. Methods: We prospectively collected the clinical data and outcomes of 902 patients who underwent CEA under general anesthesia between 2013 and 2015. All patients had preoperative computed tomography angiography of the extracranial and intracranial cerebral circulation. Indications were asymptomatic (52%) and symptomatic (48%) carotid artery disease. Patients who had CEA with shunt (n = 35) and those with inadequate intracranial imaging to assess CoW were excluded (n = 322) only. Computed tomography angiography images were reviewed retrospectively and independently by two vascular radiologists who were blinded for treatment outcomes. Imaging assessment included the vertebral and carotid circulation and each segment of the CoW, which was classified as normal, hypoplastic (diameter < 0.8 mm) or absent. The ipsilateral MCA was considered isolated if there was an absence of the anterior and posterior communicating branches from the contralateral carotid or posterior circulations. INE was defined as any transient ischemic attack (TIA) and stroke diagnosed immediately after the procedure. Results: Of the 545 included patients (331 males; mean age, 69 ± 8 years), 12 (2.2%) had a stroke in the postoperative period. There were 20 INEs (8 strokes and 12 TIAs). A complete CoW was rare; it was only detected in 19 patients (3.5%) and an iMCA was found in 34 patients (6.3%). When at least one collateral circulation was complete (in 330 patients), we observed only four INEs (1.2%). Of the 34 patients with an iMCA, 8 (24%) had INE (6 TIAs and 2 strokes). Overall, iMCA was an independent predictor of INEs (odds ratio, 11.12; 95% confidence interval, 3.57-35.87; P < .001). With logistic regression, the model included hypertension, smoking, diabetes, hyperlipidemia, carotid clamping time (minutes), contralateral significant internal carotid artery stenosis of greater than 90%, ipsilateral significant internal carotid artery stenosis of greater than 90%, preoperative symptoms in 6 months, and iMCA; above iMCA only symptomatic patients had significant risk (odds ratio, 3.34; 95% confidence interval, 1.19-9.73; P = .02), whereas all other parameters were not significant. Conclusions: An iMCA carries more than a 10-fold higher the risk of INEs after CEA with cross-clamping without shunt protection. In these patients, routine shunting is recommended to prevent INEs.

KW - Carotid endarterectomy

KW - Cerebral circulation

KW - Circle of Willis

KW - Collateral circulation

KW - Computed tomography angiography

KW - Middle cerebral artery

KW - Selective shunting

KW - Stroke

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JF - Journal of Vascular Surgery

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