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86 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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3-6
Benign Arteriogram—Bad
Ulceration
These two cases illustrate again the importance of relying on the clinical history and examination in the assessment of symptomatic carotid patients. In the rst case, the lateral view (A) demonstrates a double density in the
ICA, but no good evidence for signicant stenosis is identied. A case such as this might be passed to medical
management and regarded as an insignicant carotid artery. The AP view (B) demonstrates evidence of an ulceration in the lateral wall of the carotid bulb. This particular patient had a history of TIAs refractory to medical
therapy and was believed to be a surgical candidate. The operative specimen shown below (left) demonstrates a
signicant soft, friable intra-luminal plaque at the carotid bulb with an ulcer as identied on the AP carotid view.
In the second case, the lateral (the AP is not available) radiograph (C) shows a jagged ulcer with minimal
stenosis. The operative specimen shown below (right) again conrms a symptomatic ulcer.
This case demonstrates that although a casual view of the lateral arteriogram might not have suggested it
to be a surgical case, careful study of the lms, insistence on biplanar views, and careful reliance on the clinical
history (which is clearly consistent with carotid embolic symptomatology) justied this patient’s inclusion as a
surgical candidate. From the appearance of the operative specimen, this was clearly the appropriate decision.
CHAPTER 3: RADIOGRAPHIC STUDIES 87
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(From Loftus CM. Surgical management options to prevent ischemic stroke. Neurosurgery Quarterly 4(1):1–38,1994.)
88 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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3-7
Ninety-Five Percent Lesion
This lateral radiograph (A) of a CCA injection demonstrates a lesion with 95% stenosis at the takeoff of the ICA
from the carotid bulb. The bifurcation is relatively low, and the plaque is not particularly extensive into the ICA.
This would be considered a relatively easy arterial repair to perform.
This type of lesion is a classic representation of the lesion with >50% stenosis that the NASCET and VASST
trials have proved to be best treated by surgical reconstruction of the carotid artery.
It is also an appropriate surgical lesion in asymptomatic patients according to the ACAS and ACST data.
In (B), a similar high grade ICA stenosis is seen on CTA imaging. The yellow arrow shows the distal end of
the plaque, and the white arrow shows the ramus of the mandible, to facilitate surgical planning.
CHAPTER 3: RADIOGRAPHIC STUDIES 89
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(From Loftus CM. Surgical management options to prevent ischemic stroke. In: Adams HP Jr, ed. Handbook of Cerebrovascular
Diseases. New York: Marcel Dekker, 1993, pp. 315–358. Reprinted courtesy of Marcel Dekker, Inc.)
90 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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3-8
Extensive Plaque in Common
Carotid Artery with Long
Arteriotomy
This lateral angiographic view of a patient with carotid TIAs demonstrates a very tight stenosis (99%) at the
takeoff of the ICA and the unusual nding of a long, ulcerated plaque in the CCA as well. In my experience, this
kind of CCA plaque is seldom seen except in patients who have had radiation-induced carotid vasculopathy or
in re-operative cases. This patient was considered as an appropriate surgical candidate. The extent of the plaque
in the CCA necessitated signicantly different surgical planning. The cervical incision needed to be carried much
lower along the anterior border of the sternocleidomastoid muscle, essentially down to the level of the sternal
notch. The operative photograph demonstrates the extent of the arteriotomy in the CCA, which engendered a
long arterial suture line. The carotid reconstruction was otherwise uneventful.
In most cases of carotid endarterectomy, we go only approximately 2 cm into the CCA since the disease
is customarily located at the bulb or farther distally. As will be described in Chapter 4A: Surgical Technique,
usually a sharp transection of the plaque approximately 2 cm proximal in the CCA is adequate as long as a
clean transection is obtained. In a case such as this, however, I thought it was important that the ulcerations be
removed wherever they could be isolated and I went as far down the CCA as was necessary until I came to a
clean plane, at which point the arteriotomy was terminated.
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92 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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3-9
String Sign
This is a most interesting and illustrative case of an error in judgment in carotid planning. This patient had a
stroke referable to the ipsilateral carotid artery, and an arteriogram performed at an outside institution demonstrated what, to my mind, is a classic carotid string sign (A)—that is, a tight and almost complete stenosis at the
ICA takeoff with only the very faintest reconstitution of the distal ICA and essentially no ow of contrast up
into the intra-cranial circulation (arrow). In my estimation, this is an indication for urgent surgery. I customarily
operate on a patient such as this at the earliest possible time since the propensity for complete occlusion of such
a carotid artery is high, thereby lessening the possibility of reconstituting the normal carotid circulation. This is
the type of patient in our clinic who undergoes full heparinization and is operated on under full heparinization.
In this particular case, the arteriogram was interpreted by an outside radiologist to be a complete carotid
occlusion and the patient was sent home without any consideration of surgery. One year later, the patient presented to our clinic for consideration of a cervical laminectomy, having recovered from his stroke. At that point, I
reviewed the old carotid lms and sent him for a duplex scan, which showed anterograde ow. His arteriogram
was then repeated (B and C) and actually demonstrated a reconstitution of carotid ow with a lesion of approximately 95% stenosis but now with some ow up into the intra-cranial circulation. After explaining the situation
to the patient, an uneventful carotid endarterectomy was performed.
It is important to recognize the carotid string sign and to insist that the angiographer obtain adequate
delayed views to be certain that a putative carotid occlusion actually does not have a trace of ow warranting
immediate carotid reconstruction.
A second example of a somewhat less dramatic string sign is illustrated in (D) and (E), in which a long lesion
with 99% stenosis opens up again with good distal ow up into the cranial circulation. Once again, a case such
as this would be considered as an urgent surgical indication in either a symptomatic or asymptomatic patient.
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94 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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3-10
X-Ray Identication of an
Ascending Pharyngeal Artery
Originating at the Carotid
Bifurcation
This lateral radiograph of a left carotid artery demonstrates a high bifurcation. In addition, an important anatomic anomaly is apparent, and this type of variation must be recognized before surgery. The ascending pharyngeal artery originates from the carotid bifurcation, as indicated on the photograph. If this condition is not
recognized pre-operatively and the vessel is not controlled in the same fashion as the superior thyroid artery,
troublesome backbleeding will be the result and will render the arterial repair extremely difcult. At surgery, a
vessel like this is often found to be densely adherent to either the internal or external carotid artery and it may
not be immediately apparent that it is a separate vessel. However, when it is angiographically identied as it
has been here, a careful search must be conducted until the vessel is identied and isolated to provide adequate
hemostasis. Two similar cases are illustrated in intra-operative photographs in Figs. 4-36 and 4-37.
CHAPTER 3: RADIOGRAPHIC STUDIES 95
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