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106 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Carotid Kink
These AP (A) and lateral (B) radiographs of a CCA injection demonstrate a redundant loop or kink of the
carotid artery rather high in the cervical course of the artery and well beyond the usual range of exposure
for carotid endarterectomy. In my experience, redundant arterial loops of this kind have not been associated with
carotid embolic symptomatology, and I have not routinely resected this type of lesion.
I have found that the primary admonition regarding carotid kinks is to be aware that a redundant vessel
can form this type of kink after endarterectomy repair if circumferential dissection is done around the common
and internal carotid arteries. For this reason, I make every effort to dissect only the lateral and superior surfaces
of the artery necessary for arterial repair except at the three points where the arteries are circumferentially isolated for arterial control. When the artery is left in its bed in this way, it is much less likely to assume a redundant
coil or kink, which might interfere with the satisfactory conclusion of an arterial repair.
Please also see Fig. 6-3 for the surgical strategy of repairing a large carotid kink.
CHAPTER 3: RADIOGRAPHIC STUDIES 107
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108 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Carotid Stenosis with Distal
Cervical Aneurysm
These AP (A) and lateral (B) views demonstrate a signicant lesion at the carotid bulb and a distal aneurysm
of the ICA far beyond the usual reach and exposure of carotid endarterectomy. Since this patient was clinically symptomatic and 72 years of age and because this was her dominant hemisphere, I performed a routine
carotid endarterectomy and left the aneurysm untreated. In 8 years of follow-up, it has caused no further
problems.
CHAPTER 3: RADIOGRAPHIC STUDIES 109
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110 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Intra-Luminal Thrombus
The problem of an intra-luminal thrombus identied on arteriography in a symptomatic patient remains an area
of controversy among neurovascular surgeons. In my experience, an intra-luminal thrombus customarily propagates distal to an extremely tight stenosis in the ICA, as demonstrated in the two examples illustrated here. In
the rst (A), a single lateral radiograph demonstrates nearly complete occlusion of the ICA with a relatively low
bifurcation. However, a long lling defect is seen that propagates well up into the ICA consistent with a long,
tailing thrombus.
In the second case, a tight stenosis is again identied at the origin of the ICA with a much more signicant
lling defect that nearly obliterates the lumen of the ICA and propagates signicantly higher up to the C1-2 junction (B).
The controversy concerning intra-luminal thrombus centers on whether this represents a surgical emergency or whether a more conservative plan of management with anticoagulation is indicated before operative
intervention. Those who advance immediate surgery believe that the risk of the patient’s spontaneous embolization of this thrombus material outweighs what clearly will be higher surgical morbidity and mortality. However,
a single study performed at our own institution comparing the two treatments demonstrated that a more conservative management plan was justiable (110). It has been my concern that immediate surgery on lesions of this
kind carries a high risk for intra-operative embolization from either manipulation of the vessel in preparation
for cross-clamping or from the inability (shown particularly in the second case) to cross-clamp the ICA above the
thrombus, thus creating the possibility of fracturing off a piece with subsequent embolization.
Because of these concerns, I have elected to manage these patients in a more conservative fashion and I
immediately heparinize them and discharge them on a regimen of full warfarin anticoagulation for 6 weeks. At
that point they are brought back for follow-up arteriography, which in my experience has universally demonstrated resolution of the thrombus. This is shown in the lateral radiograph of the second patient (C), in which
the tight stenosis at the ICA continues to be seen but the previous lling defect and thrombus have completely
resolved. At this point, a safe and uneventful carotid endarterectomy can be easily performed.
The small, non-propagating type of intra-luminal thrombus is occasionally seen just at the carotid bulb, and
the presence of a small “bullet” of that type is not usually considered a contraindication to surgery in my experience. (D) is an illustration of a thrombus that does not propagate as far up the ICA and might be considered for
immediate surgery. It is only the long and propagating intra-luminal thrombi such as demonstrated here (and
which in my experience are more common) that I manage with this conservative plan, and it has yielded good
results. At the time of this writing, none of my patients on anticoagulation therapy has gone on to experience
embolic phenomena during the 6-week waiting period.
CHAPTER 3: RADIOGRAPHIC STUDIES 111
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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.)
112 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Complication—Clot along
Suture Line
This patient had an uneventful right carotid endarterectomy. His pre-operative lateral arteriogram (A) showed
an approximately 60% stenotic lesion at the common and internal carotid junction. The endarterectomy procedure was totally uneventful.
Approximately 6 hours post-operatively, the patient developed a paresis of the left hand. Arteriography
demonstrated a patent carotid tree but evidence of clot formation along the suture line (B). I elected to manage
this patient with full heparinization, and within 72 hours his hand function had essentially returned to normal.
I switched him from heparin to warfarin while in hospital and maintained him on anticoagulation for 3 months,
after which time I brought him back for a follow-up arteriogram (C), which showed resolution of the clot and
a technically satisfactory, non-stenotic arterial repair. The patient has remained neurologically intact since that
time. Please note that this case pre-dates my use of the universal Hemashield roof patch graft.
CHAPTER 3: RADIOGRAPHIC STUDIES 113
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(From Loftus CM. Surgical management options to prevent ischemic stroke. Neurosurgery Quarterly 4(1): l–38, 1994.)
114 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Complication—Complete
Post-Operative Occlusion
This patient had an uneventful carotid endarterectomy. He was also known to have a contralateral carotid occlusion. In the immediate post-operative period (approximately 1 hour after surgery), the development of a left
brachial paresis was noted and the decision was made to proceed immediately to arteriography, where complete
occlusion of the carotid artery was demonstrated. It is to be noted in this lateral radiograph that there is a small
stump at the site of the occluded ICA and also good retrograde ow by external to internal collaterals lling the
cavernous and petrous portions of the carotid artery. This retrograde ow indicates a high likelihood of the ability to re-open the vessel at surgery. This patient was immediately returned to surgery where backbleeding was
quickly established on re-opening the carotid tree. The carotid artery was then reconstructed with a saphenous
vein patch graft, and the patient made a gratifying return to normal neurologic function.
Once again, this early case pre-dates my use of the universal Hemashield roof patch graft.
CHAPTER 3: RADIOGRAPHIC STUDIES 115
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