Elsevier

World Neurosurgery

Volume 106, October 2017, Pages 813-818
World Neurosurgery

Technical Note
Effective Intraluminal Shunt in Carotid Endarterectomy for Carotid Artery Near Occlusion: Technical Report

https://doi.org/10.1016/j.wneu.2017.07.078Get rights and content

Background

Carotid artery near occlusion is a critical degree of stenosis whereby blood flow is decreased and the distal cervical and intracranial internal carotid arteries (ICAs) are prone to collapse. Considering the diminished perfusion and risk of progression to total occlusion and periocclusive embolism, we performed carotid endarterectomy for carotid artery near occlusion.

Methods

Accurate evaluation of tandem stenosis or patency of the poststenotic ICA in carotid artery near occlusion is often difficult preoperatively. Thus we performed carotid endarterectomy in a hybrid operating room where intraoperative digital subtraction angiography (DSA) and endovascular angioplasty or stenting for distal lesions can be performed if necessary. In addition, to evaluate the distal ICA intraoperatively, we used an intraluminal shunt for shunt angiography, with injection of contrast material through the shunt tube, as a replacement for conventional DSA. Furthermore, an intraluminal shunt held the collapsed lumen open and provided a scaffold for suturing, which prevented postoperative stenosis of the distal ICA.

Conclusion

The present report is intended to underline the merits of intraluminal shunt as a replacement for conventional DSA and as a scaffold for suturing.

Section snippets

Background

Carotid artery near occlusion is a critical degree of stenosis whereby blood flow is decreased and the diameter of the distal cervical internal carotid artery (ICA) is reduced.1, 2 The distal cervical and intracranial ICAs are prone to collapse,3 so accurate evaluation of tandem stenosis or the patency of a poststenotic ICA is often difficult. Moreover, the collapsed distal end tends to show a thickened wall and the diameter can be reduced.1, 2 Therefore suturing the distal end might be

Imaging Protocol

Computed tomographic angiography (CTA) or digital subtraction angiography (DSA) is preferably used to assess carotid artery stenosis. Carotid artery near occlusion was defined in accordance with the report by Fox et al.1 In brief, carotid artery near occlusion is characterized by the following: delayed arrival of the contrast medium in comparison with the arrival time in the ipsilateral external carotid artery; evidence of the collateral artery via the anterior or posterior communicating

Illustrative Case

A 74-year-old man was referred to our institute for treatment of right-side symptomatic ICA stenosis. His chief symptom was recurrent, transient, left-side hemiparesis, even with the best medical treatment. He showed near occlusion of the ICA and the string sign at the level of the fifth cervical vertebra (Figure 2A–C). Imaging to determine the plaque showed that the lesion length appeared to be approximately 3 cm (2 cm distal to the bifurcation). Fluid-attenuated inversion recovery imaging

Discussion

As the degree of ICA stenosis progresses, the velocity of the blood flow through the stenosis is inclined to increase to maintain the blood supply.1 However, carotid artery near occlusion is a critical degree of stenosis beyond compensation whereby the flow is decreased and the diameter of the distal cervical ICA is reduced.1 Although the efficacy of surgical treatment for carotid artery near occlusion is controversial,7, 8, 9, 10, 11 considering the diminished perfusion12 and risks of

Conclusion

We used an intraluminal shunt for shunt angiography intraoperatively as a replacement for conventional DSA. An intraluminal shunt held open the collapsed lumen and provided a scaffold for suturing, which prevented postoperative stenosis of the distal ICA. Intraluminal shunt use and shunt angiography are effective for carotid artery near occlusion.

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