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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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386 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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5-9
Post-CEA/CAS DWI-Positive
Lesions (Japanese case)
This 65-year-old male developed transient weakness of the left extremities and was admitted to our hospital.
Three-dimensional CT angiography revealed moderate stenosis (60%) of the right ICA with ulcer formation. He
successfully underwent CEA. During surgery, direct observation of the plaque showed the ulcer formation with
thrombus accumulation inside. Post-operative course was uneventful. However, DWI performed on the next
day revealed a DWI-positive lesion in the ipsilateral cortex. He was discharged without any neurological decits.
Previous systematic review demonstrated that such DWI-positive lesions can be identied in 37% and 10%
after CAS and CEA, respectively (Schnaudigel S et al., 2008). Microembolism is believed to most frequently occur
during carotid dissection and within the rst hour after surgery (3, 4). Therefore, very gentle handling of the
carotid artery is quite important to avoid embolic migration during surgery. However, recent developments of
surgical technique and distal lter system are decreasing the incidence of post-CEA/CAS DWI-positive lesions.
CHAPTER 5: COMPLICATIONS 387
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388 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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5-10
Femoral Artery PseudoAneurysm after Catheter
Insertion (Japanese case)
This 78-year-old female suddenly developed weakness of the right extremities and was admitted to our hospital.
Radiological examinations revealed cerebral infarction due to severe stenosis of the left ICA. Dual antiplatelet
therapy was started with aspirin and clopidogrel. Then, she underwent carotid artery stenting (CAS) through
the right femoral artery. Puncture site was closed using an Angio-Seal closure device. Post-operative course was
uneventful, but on the next day, she complained of severe pain in the right inguinal area. Physical examination
revealed subcutaneous hematoma associated with ecchymosis, tenderness, and vibration thrill. Hemoglobin
level decreased from 13.2 to 8.0 g/dL. Plain CT scan demonstrated subcutaneous hematoma around the right
femoral artery (arrow). Digital subtraction angiography (DSA) demonstrated the pseudo-aneurysm arising from
the puncture site (arrow, left). The right femoral artery was temporarily occluded with a balloon catheter and
thrombin was percutaneously injected into the pseudo-aneurysm (middle). As a result, the pseudo-aneurysm
completely disappeared. She was discharged 2 weeks after CAS without any neurological decits.
CHAPTER 5: COMPLICATIONS 389
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390 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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REFERENCES
1. Byrne JL, Zaman SN. External carotid endarterectomy under direct vision. Am J Surg. 1989; 157:243–244.
2. Kobayashi M, Yoshida K, Kojima D, Oshida S, Fujiwara S, Kubo Y, Ogasawara K. Impact of external carotid artery
occlusion at declamping of the external an common carotid arteries during carotid endarterectomy on development of
new postoperative ischemic cerebral lesions. J Vasc Surg. 2019; 69:454–461.
3. Abbott AL, Levi CR, Stork JL, Donnan GA, Chambers BR. Timing of clinically signicant microembolism after carotid
endarterectomy. Cerebrovasc Dis. 2007; 23:362–367.
4. Sato Y, Ogasawara K, Narumi S, Sasaki M, Saito A, Tsushima E, Namba T, Kobayashi M, Yoshida K, Terayama Y,
Ogawa A. Optimal MR plaque imaging for cervical carotid artery stenosis in predicting the development of microembolic signals during exposure of carotid arteries in endarterectomy: Comparison of 4 T1-weighted imaging techniques.
AJNR Am J Neuroradiol. 2016; 37:1146–1154.
CHAPTER 6
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Special Cases
391
392 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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6-1
Treatment of Isolated Common
Carotid Artery Stenosis
In this case, a 56-year-old woman had stereotypic transient ischemic attacks (TIAs) referable to the right brain
and an isolated 70% stenosis in the right common carotid artery (CCA) only. The carotid bulb and the external and internal carotid arteries were relatively free of disease. We made a decision to perform a purely CCA
endarterectomy, which is illustrated here. In (A), the vessel is seen with the blue line drawn in preparation for
arteriotomy. In (B), the artery is shown following uneventful repair and roof patch Hemashield graft placement.
An unusual case, such as this, demands special surgeon concentration on the clamping and de-clamping
steps to be certain that the brain is protected from air or debris at all times.
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394 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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6-2
Treatment of “Stump”
in an Occluded Internal
Carotid Artery
The “stump” syndrome, as described previously in the text and illustrated in Fig. 3-15, occurs when the internal
carotid artery (ICA) has occluded spontaneously, but distal to the carotid bulb, leaving a blind sac or stump. The
stump may be small or quite large. TIAs can ensue when embolic material forms in the stump and embolizes up
the ECA and into the cerebral circulation by trans-ophthalmic collateral pathways. I believe that symptomatic
stumps should be surgically repaired, although the necessity to treat asymptomatic stumps is less clear.
In these four illustrations, I show two such cases of stump repair. In (A), there is clear fresh thrombus formation within the ICA stump, which accounted for the break-off of emboli that propagated up the ECA. This
stump was oversewn and eliminated once the thrombus had been vacuumed away with suction (not shown). In
(B, C, and D), I show a second case of a symptomatic stump as well, but in this case no fresh thrombus was found
at surgery, (B) shows the orice of the stump (empty in this case) exposed via a common to external carotid endarterectomy, (C) shows this stump sewn closed with interrupted 6-0 double-armed Prolene sutures placed from
the inside out and tied so that the knots lie outside the lumen of the carotid tree (like a tacking suture). (D) shows
the placement of a roof patch to maximize ow from the common to the external carotid, and the securing and
obliteration of the stump with a large Weck clip across the base of the ICA (in addition to the oversewing step).
Some surgeons feel that simple obliteration of the stump externally with a Weck clip or silk tie is adequate,
and do not open the vessel at all. I think this is dangerous for two reasons; rst, that a clip applied externally to a
owing vessel could dislodge embolic material into the ECA and thus to the brain; and second, that an external
clip does not completely obliterate the stump as an internal exposure and oversewing step will do.
CHAPTER 6: SPECIAL CASES 395
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