Penetrating Carotid Artery Injuries. Shunts Versus No Shunts During Repair: Effect On Neurological Outcomes
John Kessler II, BS, Tharun Kotaru, BS, Louay Kalamchi, BS, Parinaz J. Dabestani, MS, Stephanie Miljkovic, MS, Juan Asensio, MD.
Creighton University School of Medicine, Omaha, NE, USA.
OBJECTIVES: Penetrating carotid artery injuries are rare even in large Trauma Centers. Repair is the preferred method versus ligation. To date, the use of temporary shunts and its relation to neurological outcomes has not been studied. No single study has a large enough number of patients nor the predictive power to define if there are neurological and overall outcome differences in patients undergoing repair with shunts versus no shunts. The objective of this study is to review the literature and report mortality rates for penetrating carotid injuries in order to answer the question. In patients with penetrating carotid injury who undergo surgical repair, does the use of temporary shunts lead to decreased mortality or improved neurologic outcome?
METHODS: A focused literature search was performed through Medline Complete-PubMed, Scopus and Ovid. Inclusion criteria: Series reporting operative management of penetrating carotid artery injury. Exclusion criteria: endovascular repair, neurosurgical techniques involving craniotomy, and studies with no reports on pre or postoperative neurological status. 31 papers were identified that meeting all criteria, ranging from 1970 to 2018. These were systematically analyzed for surgical repair with or without the use of temporary shuns for which pre- and postoperative neurological outcomes were identified. Statistics: Non-parametric data were analyzed with Fisher Exact or Chi-square tests as applicable. Data are presented as proportions. Statistical significance was set to a p-value <0.05.
RESULTS: There were a total of 849 carotid injuries; 128 cases underwent ligation and were excluded. Of the remainder, 596 underwent repair without shunts, while 125 were repaired with shunts. Mortality stratified to shunts versus no shunts was 5.6% versus 9.4% (p=0.17). Neurological improvement was greater for injuries repaired with shunts - 13.6% versus injuries repaired without shunts - 14.4% (p=0.76). Worsening neurological status with shunts - 3.2%, versus repaired without shunts - 6.5% (p=0.0098). Data were analyzed for outcome variables including neurological deficits with or without mortality. Patients shunted during repair had an improved or unchanged neurologic outcome compared to patients not - 91.2% versus 84.1% (p=0.04).
CONCLUSIONS: Shunted penetrating carotid injuries repaired with shunts maintain lower mortality and have better and/or unchanged neurological outcomes versus those repaired with temporary shunts. Based on this evidence we recommend the routine use of temporary shunts for complex repair of penetrating carotid injuries.
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