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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3643_Библиотеки_им_академика_М_И_Перельмана.pdf
286
VA
CEA
CEA
b
Fig. 13.5 (continued)
SCA
CCA
Ao
Fig. 13.6 Bypass for occluded BCT. Anatomic reconstruction for the occlusion of the BCT: bypass from the ascending aorta to the right SCA and
right CCA. Whenever the bifurcation appears diseased, the carotid limb is anastomosed to the right carotid bifurcation after CEA
H. Muresian
287
SCA
BP
VCCA
IJV
ASM
SCA
CCA
CCA
PTFE
graft
a
b
Fig. 13.7 CEA + revascularization
of the SCA. Panel ( a ) completion
angiogram illustrating the bypass
from the CCA to the occluded SCA
with PTFE graft. Note also the
retrograde fi lling of SCA branches.
Particular attention is focused on the
purging (air, thrombi) as embolic
material may pass either into the
distal CCA and ICA or into the
VA. Panel ( b ) alternative surgical
solution by using an autologous
venous graft ( G ). Note the position
of the bypass posterior to the
IJV. The ASM was cut
13 Extensive Cerebrovascular Arterial Revascularization
288
ICA
CCA
SC
PTFE
graft
ECA
Fig. 13.8 Carotid bifurcation-to-SCA bypass. The technique
includes CEA and bypass from the endarterectomized carotid to
the occluded SCA. The superior part of the PTFE graft serves as an
enlargement patch for the carotid bifurcation. The graft is tunneled
underneath the SCM
H. Muresian
289
CCA
G
ICA
ICA
CCA
G
ICA
ICA
Fig. 13.9 Extraanatomic carotid-to-carotid bypass. The fi gure illus-
trates the case of an old female patient, with severe atherosclerotic
lesions in all neck vessels, and having the only fair donor vessel, the
right CCA. The left CCA was occluded but the bifurcation remained
patent. Both carotid bifurcations had atherosclerotic lesions, requiring
the SBCE. A prelaryngeal PTFE graft ( G ) was used to revascularize the
left carotid system
13 Extensive Cerebrovascular Arterial Revascularization
290
Fig. 13.10 Bypasses from the ascending aorta. Numerous variations
and types of bypasses are performed, for the vascularization of the neck
vessels. All these variants can be easily applied in cases with aneurysms
of the aortic arch or as debranching procedures. Panel ( a ) a quadrifur-
cated graft (with the additional two branches anastomosed ad hoc) was
inserted on the ascending aorta. The branches reach the SCA on both
sides and the carotid arteries on both sides too. Note that the bifurcations
were endarterectomized (excised plaques shown in the left extremity),
and synthetic patches were inserted. Right lower Panel ( d ) demonstrates
the incisions for the combined approach: sternotomy and bilateral double parallel incisions. We prefer cervical parallel incisions instead of a
single longitudinal incision. Panel ( b ) bypass from the ascending aorta
to the left neck vessels: ICA and SCA. Note that even in this case, the
carotid limb is used as an enlargement patch. Panel ( c ) a similar recon-
struction on the right side, in case of obstruction of the BCT. Panel ( d )
completion angiogram in a patient with a quadrifurcated graft
SCA
SCA
CEA
CEA
CEA
SCA
Ao
a
b
H. Muresian
291
SCA
CCA
SCA
SCA
ICA ICA
c
d
Fig. 13.10 (continued)
13 Extensive Cerebrovascular Arterial Revascularization
292
CCA
ECA
ICA
CCA
ECA
ICA
CCA
ECA
ICA
Fig. 13.12 Revascularization of the ECA. Severe stenotic lesions at
the origin of the ECA in patients with bilateral occlusion of the ICA are
treated either by endovascular procedures (see Chap.
7 ) or by surgery.
Intraoperative aspect of the right carotid bifurcation. The ICA is
occluded (note that the ICA is declamped and no back bleeding is present). After performing the endarterectomy of the origin of the ECA, the
patch is inserted and oriented toward the ECA
Ao
BCT
Ao
BCT G
Fig. 13.11 The BCT as a donor vessel. Whenever the quality of the
ascending aorta limits the use of this vessel for bypass, or when the
patient cannot tolerate the lateral clamping of the ascending aorta, the
BCT may offer a good alternative. Preoperative diagnostic interrogation
must rule out dilatations of the ascending aorta or the presence of heavy
and extensive calcifi cations, but in some cases, this may come as an
intraoperative surprise, in spite of all the precautions previously taken.
This is also valid for coronary bypass grafting when the proximal graft
anastomosis may be performed on the BCT instead of the ascending
aorta
H. Muresian
293
Fig. 13.13 Thrombectomy of
the ICA (1). Recently thrombosed ICAs can be restored by
thrombectomy and subsequent
patching. Panel ( a ) occlusive
stenosis at the origin of the left
ICA (note also the intraplaque
hemorrhage). The end of the
thrombus appears at the origin of
the ICA. Panel ( b ) the ICA is
dethrombosed with a Fogarty
catheter. The plaque is removed
and the bifurcation is closed with
a patch. Panel ( c ) macroscopic
aspect of the excised carotid
plaque and thrombus from the
ICA. Retrograde fl ow from the
intracranial segments of the ICA
prevents distal embolization of
the thrombotic material
CCA
ECA
ICA
ICA
a
b
13 Extensive Cerebrovascular Arterial Revascularization
294
ICA
ICA
CCA
CCA
ICA
ICA thrombus
Fig. 13.14 Thrombectomy of the ICA (2). Thrombosis of the ICA
appears as an intraoperative surprise, in a patient referred for CEA, and
known to have a pre-occlusive stenosis. In the time interval from diag-
nosis to surgery, the ICA is occluded. The ICA was treated as above.
The plaque was removed by using the eversion technique
CCA
ICA thrombus
ICA
c
Fig. 13.13 (continued)
H. Muresian
295
CCA CCA CCA
ECA
ICA
ECA
ICA
ECA
ICA
Fig. 13.15 Bifurcated patch. Intraoperative aspect of the right carotid
bifurcation. The ICA appears hypoplastic (compare the diameter with
that of the ECA). Patency of the ICA was probed with a malleable catheter. With the bifurcation opened, it appears evident that the origin of
the ECA is larger, and the normal patch was inserted toward the origin
of the ECA. An additional tail of the patch is used to enlarge the origin
of the ICA. Should the ICA occlude with time, the ECA will remain
patent
13 Extensive Cerebrovascular Arterial Revascularization