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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3617_Библиотеки_им_академика_М_И_Перельмана
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10 Cervical ICA–to–Cervical ICA Interposition
Graft or Primary Reanastomosis
236 Color Atlas of Cerebral Revascularization
Lesions of the cervical carotid artery may require bypass. When a direct reanastomosis is feasible, however,
it should be the preferred method for maintaining blood fl ow in the ICA.
Fig. 10.0a The signifi cant redundancy in the ICA allows
excision of the aneurysm.
Fig. 10.0b Direct reanastomosis of the ICA.
Fig. 10.0c In an alternative option, blood fl ow is
maintained through the ICA with the use of an
interposition graft.
Cervical ICA–to–Cervical ICA Interposition Graft or Primary Reanastomosis 237
Case 10-1
Diagnosis: Complex left cervical ICA aneurysm
Bypass: Cervical ICA–to–cervical ICA primary
end-to-end reanastomosis
Approach: Left anterior cervical
Fig. 10.1a Anteroposterior angiographic view shows the aneurysm and
the redundant ICA above it.
Fig. 10.1b Right anterior oblique angiographic view also shows some
redundancy of the ICA proximal to the aneurysm.
238 Color Atlas of Cerebral Revascularization
Fig. 10.1c Through a high anterolateral incision, the carotid artery bifurcation is exposed.
Fig. 10.1d With further dissection, the base of the aneurysm is exposed.
Fig. 10.1e Overview shows CN XII coursing over the aneurysm.
Cervical ICA–to–Cervical ICA Interposition Graft or Primary Reanastomosis 239
Fig. 10.1f As the dissection is extended superiorly, the top of the aneurysm becomes visible.
Fig. 10.1g With the patient placed under barbiturate anesthesia to burst suppression, the aneurysm is isolated
between temporary aneurysm clips.
Fig. 10.1h The aneurysm is opened and the lumen is inspected.
240 Color Atlas of Cerebral Revascularization
Fig. 10.1i The aneurysm dome is mobilized and cut from the proximal and distal ICA.
Fig. 10.1j The two cut ends of the ICA are mobilized to allow a tensionless anastomosis.
Fig. 10.1k A direct end-to-end anastomosis is performed between the cut ends.
Cervical ICA–to–Cervical ICA Interposition Graft or Primary Reanastomosis 241
Fig. 10.1l The completed ICA reconstruction is shown.
m
n
Fig. 10.1m–o Inferior (m) and exterior (n) views of
excised aneurysm and internal view (o) of the irregular
lumen show why the aneurysm was a source of embolic
o
material.
242 Color Atlas of Cerebral Revascularization
Fig. 10.1p Lateral angiographic view shows excision of the
aneurysm and continued fl ow through the ICA.
Fig. 10.1q Lateral angiographic view of the right carotid
bifurcation shows the anastomosis (arrow) performed after the
aneurysm was excised.
11 Subclavian Artery–to–CCA Bypass or
Transposition
244 Color Atlas of Cerebral Revascularization
The subclavian artery, a large vessel located by the clavicle, is available as a donor site when needed. The
subclavian artery is exposed through a transverse supraclavicular incision with bisection of at least part of
the sternocleidomastoid muscle. The incision along the course of the CCA can be extended if the vessel must
be exposed for any length or if a VA-to-CCA transposition will be performed.
On the left side, it is important to recognize the presence of the thoracic duct, whose integrity should be
maintained. Once the duct and its branches have been identifi ed, it can be cut after both ends are completely
ligated. Ascertaining the anatomic location of the phrenic nerve and stellate ganglion can avoid injuries to
these structures.
Fig. 11.0a The transverse supraclavicular incision (dashed line) is shown with a longitudinal extension (dotted line).
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