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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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246 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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4-57
Potential for Intimal Damage
from Placement of Shunt
I have emphasized that the shunt needs to be inserted with the gentlest of techniques in the ICA. As described
previously, I never force a shunt if it does not slide readily up in the ICA because the advancing end of the shunt
may theoretically roughen or damage the intimal high in the ICA beyond the area of the arteriotomy, leading to dissection of the ICA with consequent thrombosis and embolic phenomena and devastating neurologic
consequences for the patient. This potential damage is illustrated in this drawing in which forceful insertion
of the shunt is shown to raise an intimal ap. Of course, this is an extremely uncommon phenomenon. In the
vast majority of my cases, the shunt is placed with absolutely no difculty up into the ICA so long as the ICA is
allowed to backbleed during the process and the shunt is held open so that antegrade ow blows the vessel walls
apart and out of harm’s way.
CHAPTER 4A: SURGICAL TECHNIQUE 247
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248 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Securing of Shunt in Internal
Carotid Artery
When the shunt has been successfully placed in the ICA, it can be secured with a small Javid clamp or with a
Loftus pinch clamp to prevent backbleeding around it. This clamp has been previously sized in the wound as
shown in Figs. 4-43 and 4-44.
CHAPTER 4A: SURGICAL TECHNIQUE 249
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250 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Loftus-Type Carotid Shunt
in Place—Two Views
The Loftus-type shunt (Integra Neuroscience, Plainsboro, NJ) is a straight silastic tube chamfered at the ICA end
for easy placement, and with a built-up bulb at the CCA end to anchor it in the Rummel tourniquet. There is a
black line at the center of the shunt to indicate migration during the case. In these two photos, we illustrate the
shunt in place with the black line properly placed at the center of the arteriotomy (A). We also show the shunt
being secured by the Loftus-type pinch clamps (Fig. 4-44) in the ICA: in (B), at the right edge of the frame, the
shunt can be seen to be secured in the CCA by the 0 silk tie within the Rummel tourniquet.
CHAPTER 4A: SURGICAL TECHNIQUE 251
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252 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Evaluation of Shunt Function
There are a number of ways to evaluate shunt function and ensure that antegrade ow is present. The simplest
is application of a handheld Doppler probe to the shunt tubing. The audible ow signal, although faint, has
conrmed patency in every case in my experience. Shunt function can also be ascertained by various monitoring
techniques, and I anticipate that the EEG or similar monitoring technique will return to baseline after satisfactory
placement of an indwelling shunt. TCD velocities are also expected to improve to at least 50% or more of their
baseline values with proper placement of a shunt.
If monitoring parameters do not improve once a shunt has been placed, a careful assessment of possible
shunt malfunction, whether through thrombosis or abutment against the distal ICA wall, is needed.
CHAPTER 4A: SURGICAL TECHNIQUE 253
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254 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Repair with Shunt in Place
In this case, the ICA repair is nearly complete and only the CCA and bulb portions of the shunt are visible. Note
that the black dot continues to mark the midpoint of the arteriotomy. In this procedure, the Rummel tourniquet
did not prove adequate to secure the shunt without some degree of minor, but annoying, antegrade bleeding,
and a large Javid clamp was placed around the CCA as a backup. This was an unusual occurrence since the vessel
loop or 0 silk encased in the Rummel tourniquet typically stops bleeding around the shunt.
CHAPTER 4A: SURGICAL TECHNIQUE 255
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