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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3643_Библиотеки_им_академика_М_И_Перельмана.pdf
255
c
d
Fig. 11.6 (continued)
11 Carotid Endarterectomy
256
e
f
Fig. 11.6 (continued)
H. Muresian
257
ICAECA
CCA
g
Fig. 11.6 (continued)
Fig. 11.7 Eversion technique. Panel ( a ): the
carotid bifurcation (and a longer segment of
the CCA in this particular case) is prepared.
Panel ( b ): the ICA and ECA are
disconnected from the CCA. The plaque on
the ICA is identifi ed and pulled out, while
the remaining arterial wall is being everted.
Panel ( c ): the same is applied in this case, to
the plaque occupying most of the cervical
portion of the CCA. Panel ( d ): a longer
plaque from the CCA is pulled out, while
the CCA is everted. Panel ( e ): the ICA and
the ECA are reanastomosed to the CCA. In
cases in which the reanastomosis might
appear stenotic or when a larger portion of
the anterior wall appears defi cient, a patch
can be also inserted. Panel ( f ): reanastomosis
completed
ICA
CCA
ECA
a
b
11 Carotid Endarterectomy
258
Fig. 11.7 (continued)
d
c
H. Muresian
259
Fig. 11.7 (continued)
ICA
ECA
CCA
e
f
11 Carotid Endarterectomy
260
ICA
ECA
CCA
a
b
Fig. 11.8 Carotid endarterectomy, resection of the CCA, and bypass.
In particular cases, the CCA appears severely diseased, either with stenotic or with ulcerated plaques. A longer endarterectomy can also be
performed over the CCA, but the remaining arterial wall might appear
to be rough and potentially thrombogenic. In such cases, we recommend the resection of the segment of the CCA and replacement with a
vascular graft. Whenever the origin of the ICA is not too slender and the
arterial wall not too thin, the direct anastomosis of the prosthesis to the
carotid bifurcation (Panel a ) can be safely performed (the distal anasto-
mosis in performed fi rst). The interior aspect of the plaque in the CCA
is presented in Panel ( b ). Alternatively, CEA can be followed by the
insertion of a patch ant the vascular graft is anastomosed to the alreadyenlarged carotid bifurcation (Fig.
11.9 )
H. Muresian
261
Fig. 11.9 Combined technique: patch plus bypass. This is applied
whenever the ICA is of a thinner texture or the diameter is reduced. The
patch allows for a safer anastomosis of the graft. The communication
between the ICA and the ECA can be declamped before completing the
anastomosis with the distal part of the graft and before performing the
proximal anastomosis on the more proximal CCA
11 Carotid Endarterectomy
262
ICA
CCA
XII
a
b
c
Fig. 11.10 Endarterectomy and “ascent” of
the carotid bifurcation. Panel ( a ):
intraoperative aspect of a carotid bifurcation
with kinking and moderate hypoplasia of the
ICA. Note the excess length of the cervical
ICA. Panel ( b ): after performing the CEA,
the excess of the ICA is trimmed, and the
ICA is reanastomosed to the ECA and CCA
(as in the regular eversion technique). Part of
the ECA is used to enlarge the entrance into
the ICA; in this way, the new carotid
bifurcation will appear as “ascending.” Panel
( c ): the remaining anterior portion of the
carotid bifurcation is completed by inserting
a synthetic patch
H. Muresian
263
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stenosis. European Carotid Surgery Trialists’ Collaborative Group.
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Trialists’ Collaborative Group. Stroke. 1994;25(12):2435.
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and interobserver variability of magnetic resonance angiography?
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SC, Kasner SE, Kittner SJ, Mitchell PH, Rich MW, Richardson D,
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© Springer International Publishing Switzerland 2016
H. Muresian (ed.), Arterial Revascularization of the Head and Neck, DOI 10.1007/978-3-319-34193-4_12
Vertebral Artery Revascularization
Horia Muresian
The vertebrobasilar arterial system represents an important
infl ow to the brain regarding not only the vascularization of
vital regions and centers but also the extent of the territory of
vascularization. It is worthwhile noticing that about 20 % of the
ischemic events in the brain occur in the vertebrobasilar system.
The clinical picture is multifaceted and protean and many times
overlooked in the context of concomitant carotid artery stenosis. Not least, less attention is given to the vertebrobasilar system as many physicians still consider that the symptoms in the
posterior circulation will amend after correction of the carotid
lesion(s). Ischemia in the vertebrobasilar system is caused
mainly by occlusive disease or dissection of the vertebral artery
(VA), basilar artery (BA), and posterior cerebral artery (PCA)
and by cardioembolism or artery-to- artery embolism (from
aorta or VA). Particular conditions are represented by dolichoectasia (dilatative arteriopathy) and the subclavian steal syndrome (vertebral steal). Dolichoectasia comprises arterial
elongation, widening, and tortuosity [
1 , 2 ] eventually leading to
brain ischemia, compression of the cranial nerves, and arterial
rupture and hemorrhage. The subclavian/vertebral steal syndrome is a cause of intermittent brain ischemia accompanied by
signs of superior limb ischemia in case of severe stenosis or
occlusion of the subclavian artery or of the brachiocephalic
trunk (BCT). It is interesting to note the fact that vertebral steal
can occur even if the V0 and V1 segments are occluded, through
developed collaterals between the V3 and SCA or ECA.
The anatomy of the vertebrobasilar system is presented in
Chap. 1 . The clinical manifestations of vertebrobasilar isch-
emia (including TIAs in the posterior circulation) were presented before in Chap. 2 .
In this chapter, the revascularization of the extracranial
arteries pertaining to the vertebrobasilar system is presented, comprising mainly the VA and, additionally, the
SCA and BCT.
The greater part of atherosclerotic lesions of the VA
involve its origin (V0) and extraosseous segment (V1). Not
infrequently, plaques originate from the SCA and extend into
the origin of the VA. Besides limited lesions, some VAs may
depict more extensive lesions of almost the entire V1 segment, making thus diffi cult or precluding reimplantation of
the VA into the CCA. In our experience, we do not routinely
reimplant the VA into the SCA, due to numerous facts: the
SCA usually present extensive atherosclerotic lesions; the
wall of the SCA is thinner than that of the CCA and more
prone to rupture; and the length of available VA must be
more extensive for reimplantation into the SCA than for
reimplantation into the CCA (the VA needs to be repositioned more distally on the SCA).
Reimplantation of the VA into the CCA (Fig. 12.1 ) This
is the easiest and more frequently applied technique if the
anatomy and the localization of the atherosclerotic plaque
allow. The surgical approach is through a supraclavicular
incision as described in Chap. 4 . The anterior scalene mus-
cle is divided. The CCA is dissected and mobilized posterior to the IJV. The quality of the wall of the CCA must be
readily assessed. It is important to evaluate the extent of
the plaque into the VA after completely dissecting the VA
from origin to the transverse process of C 6 . The distance
between the CCA and the VA must be also estimated, and
the future site of reimplantation on the CCA must be
marked with a delicate stitch. The position of the VA must
be also marked, in order to avoid torsion upon reimplantation. The same neuromonitoring applies as with carotid
surgery. After giving heparin (low dose of UFH, 2500 UI
i.v. bolus), the VA is clamped fi rst for about 3 min. If no
neurological signs (in the awake patient) or alteration of
cerebral perfusion is noticed, the VA can be safely disconnected from the SCA (in few cases, we had to insert a temporary shunt from the distal SCA into the VA). The VA is
ligated a few millimeters from its origin, and an additional
suture is inserted to secure the proximal stump. The VA is
temporarily declamped in order to appreciate the retro-
1 2
H. Muresian
Cardiovascular Surgery Department ,
The University Hospital of Bucharest , Bucharest , Romania
e-mail:
cvsurg@hotmail.com