Title: Routine or Selective Carotid Artery Shunting for Carotid Endarterectomy (and Different Methods of Monitoring in Selective Shunting)
Abstract: HomeStrokeVol. 34, No. 3Routine or Selective Carotid Artery Shunting for Carotid Endarterectomy (and Different Methods of Monitoring in Selective Shunting) Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBRoutine or Selective Carotid Artery Shunting for Carotid Endarterectomy (and Different Methods of Monitoring in Selective Shunting) Richard Bond, Kittipan Rerkasem and Peter M. Rothwell Richard BondRichard Bond From the Stroke Prevention Research Unit (R.B., P.R.), University Department of Clinical Neurology, Radcliffe Infirmary, Oxford, and the Department of Vascular Surgery (K.R.), Southampton General Hospital, Southampton, UK. , Kittipan RerkasemKittipan Rerkasem From the Stroke Prevention Research Unit (R.B., P.R.), University Department of Clinical Neurology, Radcliffe Infirmary, Oxford, and the Department of Vascular Surgery (K.R.), Southampton General Hospital, Southampton, UK. and Peter M. RothwellPeter M. Rothwell From the Stroke Prevention Research Unit (R.B., P.R.), University Department of Clinical Neurology, Radcliffe Infirmary, Oxford, and the Department of Vascular Surgery (K.R.), Southampton General Hospital, Southampton, UK. Originally published27 Feb 2003https://doi.org/10.1161/01.STR.0000059381.17983.77Stroke. 2003;34:824–825Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: February 27, 2003: Previous Version 1 Large, randomized controlled trials have shown that carotid endarterectomy is beneficial for selected patients with significant, recently symptomatic carotid stenosis.1,2 However, surgery itself carries a significant risk of stroke and death. Most perioperative strokes are ipsilateral carotid territory cerebral infarcts and some may result from the temporary interruption of blood flow that occurs while the carotid artery is clamped. The duration of interrupted blood flow can be minimized by bridging the clamped section of the artery with a shunt. Although some surgeons advocate routine shunting, others prefer to use shunts selectively or avoid them altogether.3,4 Potential disadvantages of shunting include complications such as air and plaque embolism and carotid artery dissection, and an increased risk of local complications such as nerve injury, hematoma, infection, and long-term restenosis.5 However, reliable data on these risks are limited.6 We performed a systematic review of randomized controlled trials to determine the effect of a policy of routine or selective shunting on the risk of perioperative stroke, death, and other operative complications. We also tried to identify if any one method of selecting which patients undergoing endarterectomy, under general anesthetic, require a shunt is better than any other.MethodsSimilar search strategies and inclusion criteria were used in the original (up to 1995) and updated reviews (1995 to 2000).7 Studies were included if they compared any of the following policies: routine shunting versus avoiding a shunt; selective shunting versus routine shunting; selective shunting versus avoiding a shunt—or if they examined different methods for determining the need for a shunt. Recorded endpoints were all strokes, ipsilateral strokes, all strokes and deaths, wound hemorrhage, wound infection, and ipsilateral cranial nerve injuries. The time periods examined were intraoperative, within 24 hours of surgery, within 30 days of surgery, and during the whole follow-up period. If available, long-term outcomes—such as restenosis of the operated artery, cognitive function at the end of follow-up, and the numbers of shunts inserted in trials comparing one method of monitoring with another—were also recorded. Data were analyzed on an "intention-to-treat" basis. If any of the necessary data were not reported, additional data were sought from the trialists. The analyses of surgical complications (including ipsilateral stroke) were based on all arteries randomized, whereas overall stroke and death rates were calculated per patient.ResultsThree trials fulfilled the inclusion criteria.8–10 Two trials (590 patients) compared routine shunting with no shunting. Allocation was adequately concealed in 1 trial,9 and 1 trial was quasi-randomized.8 There were crossovers between treatment arms in both trials but neither trial excluded patients after randomization, and analysis was by intention-to-treat. The treatment groups were comparable in 1 trial,8 but no baseline data were available in the other trial.9 This trial was also potentially affected by the fact that 57% of shunted patients were patched compared with 39% of nonshunted patients (P=0.0002).9 There were no losses to follow up in either trial but the duration was only 30 days. The Figure shows the pooled estimates of the risks and the odds ratios between shunted and nonshunted operations for each complication studied. The overall 30-day stroke and death rate was 5.7%, and the overall risk of death was 1.8%. No significant differences were seen in any of the recorded outcomes for shunted versus nonshunted patients. Download figureDownload PowerPointPooled absolute risks and odds of complications following carotid endarterectomy from the 2 trials of routine/selective shunting versus no shunt.8,9 Odds ratios are calculated by the standard Peto method. Significance was tested for by the Mantel-Haenszel technique. All results are calculated from 2 combined studies8,9 except nerve palsy, which was available from 1 study only.8 Death and stroke are reported per patient operated (559), whereas hemorrhage, nerve injury, and infection are reported per operation (641).The third trial, involving 131 patients, compared shunting on the basis of electroencephalographic (EEG) and carotid pressure measurement, with shunting by carotid pressure measurement alone.10 The treatment groups were comparable, but the method of randomization, blinding of outcome assessment, and duration of follow-up were unclear. Three of 72 (4.1%) patients in the combined monitoring group had ipsilateral strokes within 24 hours of surgery compared with 2 out of 70 (2.9%) in the stump pressure alone group (OR=1.47, 95% CI=0.25 to 8.68, P=0.7). There were no significant differences in wound hemorrhage (4.1% versus 1.4%, OR=2.7, 0.37 to 19.58, P=0.3) or nerve palsy (8.3% versus 7.1%, OR=1.18, 0.35 to 4.02, P=0.8), but combined monitoring resulted in the use of fewer shunts (12.5% versus 25.7%, OR=0.43, 0.18 to 0.98, P=0.05).Discussion and Implications for Future ResearchThere is still insufficient evidence from randomized controlled trials to support or refute the use of routine or selective shunting during carotid endarterectomy. Further, there is little evidence to support the use of one form of monitoring over another in selecting patients requiring a shunt. A large, randomized controlled trial would be required to assess whether shunting reduces the risk of perioperative and long-term death and stroke. Even a modest 25% reduction in the relative risk of perioperative stroke or death would result in approximately 15 fewer strokes and deaths per 1000 patients undergoing endarterectomy. However, to detect this reliably (80% power, 5% significance level) would require between 3000 and 5000 patients.11 The trial would need to be truly randomized, have long-term follow-up, and have blinded outcome by neurologists.12 Patients should be stratified by age, sex, degree of carotid stenosis, the experience of the surgeon, the use of patching, and, in selective shunting, the method of monitoring of cerebral ischemia. As regards the method of monitoring in selective shunting, until the efficacy of shunting has been demonstrated, further trials of the method of monitoring are probably not merited.Section Editor: Graeme J. Hankey, MD, FRACPFootnotesCorrespondence to Mr Richard Bond, Stroke Prevention Research Unit, Gibson Bldg, Radcliffe Infirmary Hospital, Woodstock Rd, Oxford OX2 6HE, UK. E-mail [email protected] References 1 European Carotid Surgery Trialists Collaboration. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet. 1998; 351: 1379–1387.CrossrefMedlineGoogle Scholar2 Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB, Rankin RN, Clagett GP, Hachinski VC, Sackett DL, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis: North American Symptomatic Carotid Endarterectomy Trial Collaborators N Engl J Med. 1998; 339: 1415–1425.CrossrefMedlineGoogle Scholar3 Javid H, Julian OC, Dye WS, Hunter JA, Najafi H, Goldin MD, Serry C, DeLaria GA. Seventeen-year experience with routine shunting in carotid artery surgery. World J Surg. 1979; 3: 167–177.CrossrefMedlineGoogle Scholar4 Ott DA, Cooley DA, Chapa L, Coelho A. Carotid endarterectomy without temporary intraluminal shunt: study of 309 consecutive operations. Ann Surg. 1980; 191: 708–714.CrossrefMedlineGoogle Scholar5 Salvian AJ, Taylor DC, Hsiang YN, Hildebrand HD, Litherland HK, Humer MF, Teal PA, MacDonald DB. Selective shunting with EEG monitoring is safer than routine shunting for carotid endarterectomy. Cardiovasc Surg. 1997; 5: 481–485.CrossrefMedlineGoogle Scholar6 Forssell C, Kitzing P, Bergqvist D. Cranial nerve injuries after carotid artery surgery: a prospective study of 663 operations. Eur J Vasc Endovasc Surg. 1995; 10: 445–449.CrossrefMedlineGoogle Scholar7 Bond R, Rerkasem K, Rothwell PM. Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting). Cochrane Database Syst Rev. 2002;CD000190.MedlineGoogle Scholar8 Gumerlock MK, Neuwelt EA. Carotid endarterectomy: to shunt or not to shunt. Stroke. 1988; 19: 1485–1490.CrossrefMedlineGoogle Scholar9 Sandmann W, Kolvenbach R, Willeke F. Risks and benefits of shunting in carotid endarterectomy. Stroke. 1993; 24: 1098–1099.CrossrefMedlineGoogle Scholar10 Fletcher JP, Morris JG, Little JM, Kershaw LZ. EEG monitoring during carotid endarterectomy. Aust N Z J Surg. 1988; 58: 285–288.CrossrefMedlineGoogle Scholar11 Bond R, Warlow CP, Naylor AR, Rothwell PM. Variation in surgical and anaesthetic technique and associations with operative risk in the European carotid surgery trial: implications for trials of ancillary techniques. Eur J Vasc Endovasc Surg. 2002; 23: 117–126.CrossrefMedlineGoogle Scholar12 Rothwell P, Warlow C. Is self-audit reliable? Lancet. 1995; 346: 1623.Letter.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Jahangiri F, Liang M, Huckabey M, Baloney N and Sharifi S Carotid Endarterectomy Surgeries: A Multimodality Intraoperative Neurophysiological Monitoring Approach, Cureus, 10.7759/cureus.26556 BEYAZ M, URFALI S, KAYA S, ORUÇ D, ÇÖMEZ M, HAKİMOĞLU S, KOYUNCU O, MELEK I and FANSA İ (2022) Servikal blok altında karotis endarterektomi operasyonu sonuçlarımız: Anadolu'da bir merkezde ilk uygulama, Mustafa Kemal Üniversitesi Tıp Dergisi, 10.17944/mkutfd.1061031, 13:45, (97-103) SQUIZZATO F, XODO A, TAGLIALAVORO J, ZAVATTA M, GREGO F, ANTONELLO M and PIAZZA M Early outcomes of routine delayed shunting in carotid endarterectomy for symptomatic patients, The Journal of Cardiovascular Surgery, 10.23736/S0021-9509.21.11845-2, 62:6 Kamitaki B, Tu B, Wong S, Mendiratta A and Choi H (2020) Quantitative EEG Changes Correlate With Post-Clamp Ischemia During Carotid Endarterectomy, Journal of Clinical Neurophysiology, 10.1097/WNP.0000000000000686, 38:3, (213-220), Online publication date: 1-May-2021. Kim J, Huh U, Song S, Sung S, Hong J and Cho A (2019) Outcomes of Carotid Endarterectomy according to the Anesthetic Method: General versus Regional Anesthesia, The Korean Journal of Thoracic and Cardiovascular Surgery, 10.5090/kjtcs.2019.52.6.392, 52:6, (392-399), Online publication date: 5-Dec-2019. Cheng W, Lu H and Hu Y (2018) Influence of Contralateral Carotid Occlusion on Outcomes After Carotid Endarterectomy: A Meta-Analysis, Journal of Stroke and Cerebrovascular Diseases, 10.1016/j.jstrokecerebrovasdis.2018.05.023, 27:10, (2587-2595), Online publication date: 1-Oct-2018. Lee J, Huh U, Song S, Chung S, Sung S and Cho H (2016) Regional Anesthesia with Dexmedetomidine Infusion: A Feasible Method for the Awake Test during Carotid Endarterectomy, Annals of Vascular Diseases, 10.3400/avd.oa.16-00049, 9:4, (295-299), . Perez W, Dukatz C, El-Dalati S, Duncan J, Abdel-Rasoul M, Springer A, Go M and Dzwonczyk R (2015) Cerebral oxygenation and processed EEG response to clamping and shunting during carotid endarterectomy under general anesthesia, Journal of Clinical Monitoring and Computing, 10.1007/s10877-014-9657-4, 29:6, (713-720), Online publication date: 1-Dec-2015. Ciccozzi A, Angeletti C, Guetti C, Pergolizzi J, Angeletti P, Mariani R and Marinangeli F (2014) Regional anaesthesia techniques for carotid surgery: the state of art, Journal of Ultrasound, 10.1007/s40477-014-0094-5, 17:3, (175-183), Online publication date: 1-Sep-2014. Nigro G, Gatta E, Pagliariccio G, Grilli C and Carbonari L (2014) Use of the Gore Hybrid Vascular Graft in a challenging high-lying extracranial carotid artery aneurysm, Journal of Vascular Surgery, 10.1016/j.jvs.2013.04.044, 59:3, (817-820), Online publication date: 1-Mar-2014. Inoue T, Tsutsumi K, Ohwaki K, Tamura A, Ono H, Saito I and Saito N (2013) Stratification of intraoperative ischemic impact by somatosensory evoked potential monitoring, diffusion-weighted imaging and magnetic resonance angiography in carotid endarterectomy with routine shunt use, Acta Neurochirurgica, 10.1007/s00701-013-1858-y, 155:11, (2085-2096), Online publication date: 1-Nov-2013. Eckstein H, Assadian A, Kühnl A and Berger H (2012) Supraaortale Gefäße Operative und interventionelle Gefäßmedizin, 10.1007/978-3-642-01709-4_20, (381-421), . Müller D, Lohmeyer J, Zimmermann A, Siewert J, Kovacs L and Machens H (2011) Gefäßanschluss an die A. carotis communisThe carotid artery as recipient vessel, Der Chirurg, 10.1007/s00104-010-1992-5, 82:8, (670-674), Online publication date: 1-Aug-2011. Shang Y, Cheng R, Dong L, Ryan S, Saha S and Yu G (2011) Cerebral monitoring during carotid endarterectomy using near-infrared diffuse optical spectroscopies and electroencephalogram, Physics in Medicine and Biology, 10.1088/0031-9155/56/10/008, 56:10, (3015-3032), Online publication date: 21-May-2011. Ritter J, Green D, Slim H, Tiwari A, Brown J and Rashid H (2011) The Role of Cerebral Oximetry in Combination with Awake Testing in Patients Undergoing Carotid Endarterectomy under Local Anaesthesia, European Journal of Vascular and Endovascular Surgery, 10.1016/j.ejvs.2010.12.009, 41:5, (599-605), Online publication date: 1-May-2011. Sokol D, Fiedler J, Chlouba V, Bombic M and Priban V (2010) Endarterectomy for asymptomatic carotid artery stenosis under local anaesthesia, Acta Neurochirurgica, 10.1007/s00701-010-0806-3, 153:2, (363-369), Online publication date: 1-Feb-2011. Elhammady M, Heros R and Morcos J (2011) Surgical Management of Asymptomatic Carotid Stenosis Stroke, 10.1016/B978-1-4160-5478-8.10076-4, (1403-1416), . Erickson K and Cole D (2010) Carotid artery disease: stenting vs endarterectomy, British Journal of Anaesthesia, 10.1093/bja/aeq319, 105, (i34-i49), Online publication date: 1-Dec-2010. Moritz S, Schmidt C, Bucher M, Wiesenack C, Zimmermann M, Schebesch K, Kasprzak P and Metz C (2010) Neuromonitoring in Carotid Surgery: Are the Results Obtained in Awake Patients Transferable to Patients Under Sevoflurane/Fentanyl Anesthesia?, Journal of Neurosurgical Anesthesiology, 10.1097/ANA.0b013e3181e16e14, 22:4, (288-295), Online publication date: 1-Oct-2010. Baldinelli F, Pedrazzoli R, Ebner H and Auricchio F (2010) Asleep-Awake-Asleep Technique During Carotid Endarterectomy: A Case Series, Journal of Cardiothoracic and Vascular Anesthesia, 10.1053/j.jvca.2010.02.009, 24:4, (550-554), Online publication date: 1-Aug-2010. O'Kelly C, Butcher K, Marchak B and Findlay J (2014) Carotid Revascularization: An Update, Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques, 10.1017/S0317167100010210, 37:3, (320-335), Online publication date: 1-May-2010. Ahmad N, Boutron I, Moher D, Pitrou I, Roy C and Ravaud P (2009) Neglected external validity in reports of randomized trials: The example of hip and knee osteoarthritis, Arthritis & Rheumatism, 10.1002/art.24279, 61:3, (361-369), Online publication date: 15-Mar-2009. Trivedi R, Weerakkody R, Turner C and Kirkpatrick P (2009) Carotid artery stenosis—an evidence-based review of surgical and non-surgical treatments, British Journal of Neurosurgery, 10.1080/02688690902814741, 23:4, (387-392), Online publication date: 1-Jan-2009. Rerkasem K, Rothwell P and Rothwell P (2008) Local versus general anaesthesia for carotid endarterectomy Cochrane Database of Systematic Reviews, 10.1002/14651858.CD000126.pub3 Guay J (2008) Regional anesthesia for carotid surgery, Current Opinion in Anaesthesiology, 10.1097/ACO.0b013e328308bb70, 21:5, (638-644), Online publication date: 1-Oct-2008. Aleksic M, Luebke T, Heckenkamp J, Gawenda M, Reichert V and Brunkwall J (2008) Implementation of an Artificial Neuronal Network to Predict Shunt Necessity in Carotid Surgery, Annals of Vascular Surgery, 10.1016/j.avsg.2008.04.004, 22:5, (635-642), Online publication date: 1-Sep-2008. Aleksic M, Luebke T, Heckenkamp J, Gawenda M, Reichert V and Brunkwall J (2008) Utilidad de una red neuronal artificial para predecir la necesidad de derivación endoluminal en la cirugía carotídea, Anales de Cirugía Vascular, 10.1016/j.acvsp.2008.10.005, 22:5, (688-695), Online publication date: 1-Sep-2008. Aleksic M, Luebke T, Heckenkamp J, Gawenda M, Reichert V and Brunkwall J (2008) Mise en œuvre d'un réseau neuronal artificiel pour prédire la nécessité d'un shunt carotidien, Annales de Chirurgie Vasculaire, 10.1016/j.acvfr.2008.10.005, 22:5, (689-696), Online publication date: 1-Sep-2008. Meerwaldt R, Lansink K, Blomme A and Fritschy W (2008) Prospective Randomized Study of Carotid Endarterectomy with Fluoropassiv™ Thin Wall Carotid Patch versus Venous Patch, European Journal of Vascular and Endovascular Surgery, 10.1016/j.ejvs.2008.02.009, 36:1, (45-52), Online publication date: 1-Jul-2008. Schnaudigel S, Gröschel K, Pilgram S and Kastrup A (2008) New Brain Lesions After Carotid Stenting Versus Carotid Endarterectomy, Stroke, 39:6, (1911-1919), Online publication date: 1-Jun-2008. Maharaj R (2008) A Review of Recent Developments in the Management of Carotid Artery Stenosis, Journal of Cardiothoracic and Vascular Anesthesia, 10.1053/j.jvca.2007.09.014, 22:2, (277-289), Online publication date: 1-Apr-2008. Rössel T, Litz R, Heller A and Koch T (2008) Anästhesie zur KarotischirurgieAnesthesia for carotid artery surgery, Der Anaesthesist, 10.1007/s00101-008-1312-3, 57:2, (115-130), Online publication date: 1-Feb-2008. HOSODA K (2008) Tips and Pitfalls of Carotid Endarterectomy, Surgery for Cerebral Stroke, 10.2335/scs.36.155, 36:3, (155-162), . Lee T, Hines G and Feuerman M (2008) Significant Correlation between Cerebral Oximetry and Carotid Stump Pressure during Carotid Endarterectomy, Annals of Vascular Surgery, 10.1016/j.avsg.2007.07.022, 22:1, (58-62), Online publication date: 1-Jan-2008. Lee T, Hines G and Feuerman M (2008) Correlación significativa entre la oximetría cerebral y la presión en el muñón carotídeo durante la endarterectomía carotídea, Anales de Cirugía Vascular, 10.1016/j.acvsp.2008.04.011, 22:1, (64-69), Online publication date: 1-Jan-2008. Lee T, Hines G and Feuerman M (2008) Corrélation significative entre l'oxymétrie cérébrale et la pression carotidienne résiduelle au cours de l'endartériectomie carotidienne, Annales de Chirurgie Vasculaire, 10.1016/j.acvfr.2008.04.010, 22:1, (63-68), Online publication date: 1-Jan-2008. Woodworth G, McGirt M, Than K, Huang J, Perler B and Tamargo R (2007) SELECTIVE VERSUS ROUTINE INTRAOPERATIVE SHUNTING DURING CAROTID ENDARTERECTOMY, Neurosurgery, 10.1227/01.neu.0000306094.15270.40, 61:6, (1170-1177), Online publication date: 1-Dec-2007. Aleksic M, Heckenkamp J, Gawenda M, Reichert V and Brunkwall J (2007) Evaluation of Changes of Systemic Blood Pressure and Shunt Incidence in CEA, European Journal of Vascular and Endovascular Surgery, 10.1016/j.ejvs.2007.05.020, 34:5, (540-545), Online publication date: 1-Nov-2007. Mayer R, Bingley J, Westcott M, Deshpande A, Davies M, Lovelock M, Vidovich J, Doyle J, Denton M and Gurry J (2007) INTRAOPERATIVE NEUROLOGICAL CHANGES IN 1665 REGIONAL ANAESTHETIC CAROTID ENDARTERECTOMIES PREDICTS POSTOPERATIVE STROKE, ANZ Journal of Surgery, 10.1111/j.1445-2197.2006.03976.x, 77:1-2, (49-53), Online publication date: 1-Jan-2007. Chou R, Fu R, Carson S, Saha S and Helfand M (2007) Methodological shortcomings predicted lower harm estimates in one of two sets of studies of clinical interventions, Journal of Clinical Epidemiology, 10.1016/j.jclinepi.2006.02.021, 60:1, (18-28), Online publication date: 1-Jan-2007. Koch M, Cristiani M and Schmartz D (2006) Incorrect Shunt Placement Due to Anatomic Variations of the Aortic Arch During Carotid Endarterectomy: A Rare Cause of Perioperative Ischemia?, Anesthesia & Analgesia, 10.1213/01.ane.0000246423.84622.c5, 103:6, (1617-1618), Online publication date: 1-Dec-2006. McGirt M, Woodworth G, Brooke B, Coon A, Jain S, Buck D, Huang J, Clatterbuck R, Tamargo R and Perler B (2006) Hyperglycemia Independently Increases the Risk of Perioperative Stroke, Myocardial Infarction, and Death after Carotid Endarterectomy, Neurosurgery, 10.1227/01.NEU.0000215887.59922.36, 58:6, (1066-1073), Online publication date: 1-Jun-2006. Ali T, Sabharwal T, Dourado R, Padayachee T, Hunt T and Burnand K (2005) Sequential cohort study of Dacron® patch closure following carotid endarterectomy, British Journal of Surgery, 10.1002/bjs.4808, 92:3, (316-321), Online publication date: 26-Feb-2005. Kalkman C (2004) Con: routine shunting is not the optimal management of the patient undergoing carotid endarterectomy, but neither is neuromonitoring, Journal of Cardiothoracic and Vascular Anesthesia, 10.1053/j.jvca.2004.03.028, 18:3, (381-383), Online publication date: 1-Jun-2004. Mille T, Tachimiri M, Klersy C, Ticozzelli G, Bellinzona G, Blangetti I, Pirrelli S, Lovotti M and Odero A (2004) Near Infrared Spectroscopy Monitoring During Carotid Endarterectomy: Which Threshold Value is Critical?, European Journal of Vascular and Endovascular Surgery, 10.1016/j.ejvs.2004.02.012, 27:6, (646-650), Online publication date: 1-Jun-2004. Papworth D (2004) Intraoperative monitoring during vascular surgery, Anesthesiology Clinics of North America, 10.1016/j.atc.2004.02.002, 22:2, (223-250), Online publication date: 1-Jun-2004. TENJIN H, KAWABE T, HAYASHI Y, INOUE Y, OSAKA Y, HOURI T, NAKAHARA Y, TAKEMI K and KUBO S (2004) Carotid Endoarterectomy Using Patch Graft, Surgery for Cerebral Stroke, 10.2335/scs.32.49, 32:1, (49-54), . March 2003Vol 34, Issue 3 Advertisement Article InformationMetrics https://doi.org/10.1161/01.STR.0000059381.17983.77PMID: 12624319 Manuscript receivedMay 22, 2002Manuscript acceptedMay 28, 2002Originally publishedFebruary 27, 2003 PDF download Advertisement