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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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306 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Removal of Shunt
When a shunt has been used, it will be necessary to remove it before nal closure of the vessel. I do this in the
following fashion. When there is approximately 1 cm of open vessel remaining, I use two small straight mosquito
clamps introduced within the lumen to clamp the shunt closed with approximately 5 mm of open shunt between
them. I then use straight scissors to cut the shunt in half, being certain to ensure that I do not cut the back wall
in the process. The Javid or Loftus clamp is then removed from the ICA, and the distal end of the shunt is slid
back and removed from the wound. A bulldog clamp is quickly reapplied to minimize backbleeding. The CCA
end of the shunt is then removed by pulling it up out of the lumen at the carotid bulb. It is not necessary to signicantly loosen the Rummel tourniquet to remove the shunt; doing so promotes bleeding. Once the shunt has
been removed from the CCA, the DeBakey cross-clamp is immediately applied to minimize antegrade bleeding
and the Rummel tourniquet is released completely. The most common error in shunt removal is to entangle the
Prolene in the straight mosquito clamps used to double clamp the shunt. One must take great caution to ensure
that this does not happen because Prolene tangled in the mosquito clamp will hamper removal of the cut shunt
at exactly the worst possible time.
This process must proceed quickly. The patient is ischemic during shunt removal since the carotid tree is
completely closed and the monitoring system—whether EEG, TCD, or SSEP—will most likely demonstrate ischemia once again. The standard measurement for ischemic time during shunt removal and completion of repair
is 5 minutes, but in my experience it customarily takes a minute or two less.
Once the shunt has been removed, the needle is picked up from one end of the suture line (usually the internal since the primary surgeon will most likely be performing this step) and I proceed to nish with the closure of
the vessel. The nal evacuation of air, backbleeding, and lling of the vessel with heparin saline are performed
in the same fashion as will be described for cases in which a shunt has not been used.
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Tying Together—Evacuation of
Air: Right Carotid Exposure
A rigid protocol must be followed for the reconstitution of ow in the clamped carotid tree. When the suture
line is completed in the ICA, a second suture line comes up the CCA. These suture lines meet in the region of
the carotid bulb and are eventually tied together. First, however, all three vessels are backbled, usually in the
sequence of internal, external, and common carotid arteries. I hold a nger over the suture line to prevent blood
from spraying the surgeon or assistant’s face when the CCA is briey opened. With a little practice, no more than
1 or 2 mL should escape during this process. When the vessels have been backbled and it is clear that no thrombosis of a distal vessel has occurred or inadvertent stenosis has been created by the suture line, the vessels are
ready for nal closure. On rare occasions, ICA backbleeding will be inadequate; this is most often a consequence
of having a 0 silk string pulled taut by a mosquito clamp, holding the vessel closed even when the bulldog
clamp has been released. With gentle relaxation of this occluding silk, backbleeding usually ensues. In a case of
true backbleeding failure, it may be necessary to advance an exploratory shunt tube up the ICA, drawing back
with suction to re-establish ow, just as in the case of complete thrombosis of the carotid tree. This technique is
illustrated in Fig. 5-3. Failing this, a Fogarty catheter also may be used to re-establish ow. Fortunately, this is an
extremely rare occurrence (Fig. 5-4).
When adequate backbleeding is ensured and air and debris have been ushed free by this process, a syringe
with heparinized saline and a long blunt needle is introduced into the arterial lumen between the two stitches in
the region of the carotid bulb. The stitches are held taut by the primary surgeon, and a surgeon’s knot is thrown
but not drawn tight. The lumen is then lled with heparinized saline until the carotid tree bulges. As this lling
process is taking place, all nal air and debris are expelled and the surgeon’s knot is taken down to secure the
two stitches. I then use nine more single throws to ensure an adequate closure.
Occasionally, a large leak develops from the pressure of the heparin saline infusion. At this point I stop,
throw a single stitch across the point of leakage, and continue to close the vessel in the same fashion, repeating
the heparinized saline ushing step.
When all the knots are thrown, the ends of the stitches are left long; if a leak occurs in the region of the
carotid bulb, it can then be controlled by taking another bite with the attached needle and retying.
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Blunt Needle to Evacuate
Air and Debris as Final Step
—Patch Graft
Here is an even better illustration of the blunt needle evacuation technique in a case with a Hemashield roof
patch. One can appreciate that a small opening is left at the mid-point of the lateral wall. After backbleeding all
three vessels, the heparinized saline in the syringe is slowly infused by the assistant, lling the vessel while the
primary surgeon ties both sutures together, after which the needle is withdrawn. Needless to say, we do not tie
the sutures until the runback is pure saline, without air bubbles or debris.
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Four Rip-Stop Free Sutures in
the Patch Repair
For the past 10 years or so, we have begun placing four free stitches of 6-0 Prolene in the completed repair. We
place two of these sutures on each side, one about a quarter-way down from the ICA anchor, and one about a
quarter-way up from the CCA anchor. They are free stitches tied individually. We do this out of an abundance
of caution. If somehow the main suture line were to dehisce (we have never seen this happen), these four free
sutures would provide some support and hold the vessel properly closed until an emergency repair could be
done. The four paper arrowheads in this picture demonstrate the positions of the four “rip-stop” sutures.
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Sequence of Clamp Removal at
Completion of Arteriotomy
Once the vessel has been completely closed, it is ready for clamp removal. I remove the clamp rst from the ECA,
and immediately afterward from the CCA. I then wait 10 seconds, allowing any air and debris to ush up the
ECA, and then I remove the ICA cross-clamp, after which time the electroencephalographer is notied that the
circulation has been restored.
The purpose of this procedure is to ensure that the ICA is protected at all times. By opening the ECA followed rst by the CCA, any residual material will ush into the face, where it will be of no consequence. Until I
am certain that there is no potential for untoward embolization of foreign material, under no circumstances will
I open an ICA clamp and expose the brain to antegrade ow.
Occasional leaks along the suture line may become evident at this point. Frank pumping leaks often need
to be repaired with an accurately placed single stitch of 6-0 Prolene. It is rarely necessary to reapply clamps to
accomplish this, and I prefer not to interrupt the carotid circulation once it has been re-established, if at all possible. Smaller, oozing points will typically dry up with the application of Surgicel gauze and gentle pressure to
the entire suture line.
I do not close the wound until complete hemostasis along the suture line is ensured and the overlying Surgicel gauze has turned completely black.
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