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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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376 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Use of Fogarty Catheters to
Re-Open Thrombosed Internal
Carotid Artery
If satisfactory backbleeding is not obtained with the method previously described for thrombus removal with
a shunt tubing on a blunt needle, a Fogarty catheter can be used instead. The problem with Fogarty catheters
involves documented reports of the creation of a carotid cavernous stula by inating the balloon in the cavernous carotid artery. Nonetheless, if there is no other technique available to re-establish backbleeding, a Fogarty
catheter is a useful choice. As shown in the illustration, it is advanced up into the region of thrombus. The balloon is then inated and the catheter is withdrawn, pulling thrombus with it. It may be necessary to repeat this
step several times before adequate backbleeding is obtained. It should be emphasized that copious backbleeding
rather than a mere trickle should be the endpoint with either method and in the absence of signicant backbleeding, it may be wiser to perform a stump ligation and closure of the ICA rather than settling for re-establishment
of ow with an upstream thrombus that will then be catapulted up into the intra-cranial circulation.
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378 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Post-Operative Wound
Hematoma
These two illustrations show an AP (A) and lateral view (B) of a patient who developed a post-operative wound
hematoma on the rst day. This particular patient had a prosthetic cardiac valve and was maintained on full
heparinization post-operatively before being converted back to coumadin. He was neurologically intact and had
no airway problems. We were concerned about an aneurysm, of course; however, duplex scanning conrmed
an intact carotid repair with no evident problems, and the hematoma resolved spontaneously without further
issues. I feel strongly that a wound hematoma such as this needs to be investigated in some way to conrm the
integrity of the repair, whether by duplex, MRA, CTA, or catheter angiography.
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380 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Aneurysm Formation 4 Years
Post-Operatively
This case is of an older woman who had an uneventful left CEA with Hemashield roof patch 4 years prior to this
event. She was neurologically intact. She presented to our ENT service with a neck mass (A) not related to any
inciting event; specically, she reported no trauma or heavy exertion, also no pain or bleeding. The radiologists
read both her CT and MRI/MRA scans as being normal. Nonetheless, I was sufciently concerned that I ordered
catheter angiography (B), which demonstrated this aneurysmal segment along the repair. She was treated with
a stent with good results, and the mass resolved with no complications of any kind.
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382 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Post-CEA Hyperperfusion
Syndrome (Japanese case)
This 80-year-old male developed transient weakness of the right extremities and was admitted to our hospital.
Diffusion-weighted MRI (DWI) demonstrated fresh cerebral infarcts in the MCA-ACA borderzone. MR angiography showed very tight stenosis (>95%) of the left ICA (arrow). On
was markedly reduced in the left cerebral hemisphere. He was treated with continuous infusion and heparin,
but repeated the attacks of right hemiparesis, motor aphasia, and syncope every day. Therefore, he underwent
CEA ahead of schedule. CBF measurement was repeated just after surgery, which showed a marked elevation of
CBF in the left cerebral hemisphere (POD0). He was diagnosed as having post-operative hyperperfusion. Several hours later, he complained of severe headache on the left side. Therefore, his blood pressure was kept lower
than usual in order to prevent intracerebral hemorrhage, using continuous administration of anti-hypertensive
agent. Repeated CBF measurement on the third day after surgery (POD3) revealed a complete resolution of postoperative hyperperfusion and CBF normalization. He was discharged 10 days after surgery.
123
I-IMP SPECT, cerebral blood ow (CBF)
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384 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Post-CEA Occlusion of External
Carotid Artery (Japanese case)
This 75-year-old female suddenly developed weakness of the left extremities and was admitted to our hospital. MR angiography revealed very tight stenosis of the right ICA, which was associated with the reduction of
ow signal in the distal ICA. The right external carotid artery (ECA) was also stenotic (arrow). She successfully
underwent CEA, and post-operative course was uneventful. However, MR angiography performed 3 days after
surgery demonstrated the unexpected occlusion of the right ECA (arrowhead), although right ICA stenosis was
resolved. On intra-operative indocyanine green (ICG) videoangiography, the ECA was patent after the closure
of carotid arteriotomy, thus ECA occlusion was considered to have occurred with a delay in the post-operative
period.
Unexpected ECA occlusion has been reported to occur in 4%–8% during or after standard CEA (1,2). For-
tunately, no complications occurred in this case, but emboli from the ECA stump can stray into the ICA and
cause ischemic stroke. Therefore, if thick plaque remains at the extremity of the ECA at the end of the standard
endarterectomy, an endarterectomy should be performed without hesitation by adding a new arteriotomy to the
ECA as well.
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