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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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396 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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CHAPTER 6: SPECIAL CASES 397
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398 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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6-3
Repair and Straightening of
aLarge Left Carotid Kink
This patient had a right cavernous carotid aneurysm that was scheduled for endovascular balloon sacrice of the
proximal carotid. At angiography she was found to have a signicant, ow-limiting kink in the left ICA. Both
the patient and the interventional radiologist requested that this kink be surgically reconstructed to maximize
ow prior to her carotid sacrice.
The surgical procedure is shown in (A) and (B). In (A), the carotid tree has been completely dissected out
and the double kink is easily seen in the ICA. The dissection needed to be much more extensive than a routine
endarterectomy because of the need to mobilize circumferentially around the ICA and to uncoil/unravel the
kink.
Once this was accomplished, the next question was how to best maintain the vessel in the unkinked state.
One choice would have been shortening the vessel with an end-to-end ICA anastomosis. I chose, however, to
place a Hemashield roof patch to stiffen and straighten the vessel, and then I anchored both sides to the surrounding soft tissues with 6-0 Prolene “angiopexy” anchoring stitches, as illustrated in (B). The post-operative
angiogram, obtained at the time of right carotid sacrice, showed a straight and widely patent repair, and the
balloon occlusion proceeded without incident or neurological events.
CHAPTER 6: SPECIAL CASES 399
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400 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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6-4
Rapid Recurrence of Stenosis
from Myointimal Hyperplasia
There are two main causes of recurrent stenosis, aside from technical error. These are myointimal hyperplasia,
which is usually rapid in onset, and recurrent atheromatous disease, which takes longer to develop. In the case
illustrated here, a 45-year-old man with familial hyperlipidemia was operated by me with an 80% asymptomatic
stenosis without a patch graft (this is an older case of mine). He returned 6 months later with routine duplex
scans that showed a rapid recurrence (90% stenosis), and he chose to be re-operated with a roof patch (in this case
a saphenous vein patch) as I recommended to him. At surgery, we found a thickened brotic vessel wall with no
real evidence of atheroma. A plane was developed with some difculty and an uneventful patch graft repair was
performed, after which he did well in long-term follow-up, with no late evidence of recurrence.
CHAPTER 6: SPECIAL CASES 401
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402 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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6-5
Scarring in the Carotid Sheath
in a Case of Recurrent Stenosis
An operation for recurrent stenosis is signicantly more difcult than a primary endarterectomy because of the
inevitable scarring in the carotid sheath, which distorts the normal anatomy and obscures the usual tissue planes
of dissection. I illustrate here an example of recurrent stenosis. The principle in this surgery is to identify the CCA
as quickly as possible and dissect up directly over the vessel wall to obtain the requisite exposure. The vascular
pickups in this photograph are holding up the tough scar tissue that overlies the common carotid, and one can
appreciate the plane underneath this which should be blunt/sharp dissected with the Metzenbaum Scissors. The
positions of the jugular vein and vagus and hypoglossal nerves may be distorted, and in my experience the best
way to avoid damage to adjacent structures is to stay close to the artery and peel all other tissues gently away
from it.
CHAPTER 6: SPECIAL CASES 403
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404 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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6-6
Re-Operation in a Case
Previously Repaired with a
Saphenous Vein Roof Patch
This patient was presented to me by our neurology service fully heparinized with crescendo TIAs and recurrent
stenosis, 2 years after repair elsewhere with a saphenous vein roof patch. In (A), the lateral angiogram showed
tight stenosis in the distal ICA. I approached the case with caution, concerned that we would encounter a thin,
friable vessel wall with a high likelihood of premature bleeding. The clinical situation was quite different than I
had anticipated. (B) shows that the vein patch had actually completely endothelialized and was rm, thick, and
easily dissected. The only real way we could tell which was vein and which was native vessel was from the old
Prolene suture line. We performed a routine endarterectomy, taking care of course to remove all the old suture
fragments, and then placed a Hemashield roof patch (C), after which the patient had a routine and uncomplicated post-operative course.
CHAPTER 6: SPECIAL CASES 405
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