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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3660_Библиотеки_им_академика_М_И_Перельмана
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236 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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4-52
Shunt in Common Carotid
Artery/Internal Carotid Artery
I previously used a shunt fashioned from a pediatric No. 8 feeding tube cut 15 cm in length. As we have said,
this style shunt is now manufactured as a “Loftus shunt” (see Fig. 4-59). A pre-existing black dot at the middle
of the tube becomes the midpoint of the shunt after it is placed. The dot serves as a marker for positioning in the
center of the lumen to prevent unnoticed cephalad migration. I nd this less cumbersome than placing a string
around the shunt, which may interfere with the repair. The shunt is secured by a Rummel tourniquet in the
CCA (Fig. 4-45) and by a small Javid clamp or the Loftus pinch clamp in the distal ICA, as previously described
(Figs. 4-43 and 4-44). The handheld Doppler probe can be applied to this exposed shunt tubing, and an audible
ow signal will be faintly heard, conrming shunt patency. Shunt function is also assessed by noting return of
monitoring parameters to baseline (whether EEG, TCD, SSEP, or other methods are used).
CHAPTER 4A: SURGICAL TECHNIQUE 237
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238 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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4-53
Initial Placement of Shunt Down
Common Carotid Artery
As mentioned earlier in the text, it is my preference to place a shunt in the CCA rst. I have ensured that the
cross-clamp is at least 1 cm below the Rummel tourniquet. This drawing illustrates placement of the shunt down
the CCA and through the Rummel tourniquet until it abuts against the clamp. The Rummel tourniquet is then
secured as shown in the drawing, after which the clamp can be released and the shunt can be advanced farther
caudally until essentially all of the shunt is down the CCA.
CHAPTER 4A: SURGICAL TECHNIQUE 239
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240 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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4-54
Securing of Shunt in Common
Carotid Artery
This is a detailed view of the securing of the shunt in the CCA. When the shunt is placed, the DeBakey clamp
is not removed from the CCA, but rather the shunt is placed down to the level of the DeBakey clamp and then
the Rummel tourniquet is secured around it. After this, the DeBakey clamp can be removed without signicant
bleeding, and the shunt is advanced in retrograde fashion down the CCA.
CHAPTER 4A: SURGICAL TECHNIQUE 241
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242 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Bleeding and Evacuation of
Shunt before Placement in
Internal Carotid Artery
Once the shunt has been placed and secured in the CCA and has slid down satisfactorily, the DeBakey forceps
that are holding the plastic tubing closed are released until the entire shunt lumen is lled with a solid column
of blood and all air and debris have been evacuated from it. In this fashion, one can be certain that no atheroma
dislodged from placement of the shunt remains in the lumen where it might inadvertently be sent up the ICA.
The ability to evacuate any possible atheroma is the reason I place this shunt in the CCA rst, and only when I
am certain that there is no foreign material present do I place it in the ICA.
CHAPTER 4A: SURGICAL TECHNIQUE 243
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244 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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4-56
Placement of Shunt in Distal
Internal Carotid Artery
When the shunt lumen has been evacuated, suction is used to completely empty the ICA of blood or residual
debris. The assistant then removes the bulldog clamp allowing the ICA to backbleed. At the same time, the shunt
is advanced up the backbleeding ICA in the gentlest possible fashion; when it has been initially placed, the
DeBakey forceps can be removed allowing the shunt to bleed forward as well. This process of antegrade bleeding
in the shunt blows opens the ICA to some extent and prevents the shunt from abutting against the vessel wall. If
there is the least bit of resistance to passage of the shunt, I stop, remove it, and try again, but it usually slides up
quite freely without a problem. The shunt is advanced until the black dot appears in the center of the wound at
the region of the carotid bulb. This black dot has 7½ cm of shunt on either side of it and ensures that the shunt is
properly placed. It serves as a marker throughout the operative procedure to prevent unnoticed cephalad migration of the shunt with possible dislodgment from the CCA.
CHAPTER 4A: SURGICAL TECHNIQUE 245
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