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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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406 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Hypoglossal nerve
External carotid artery
Internal carotid artery
Superior thyroid artery
Hemashield patch graft replaces
previous saphenous vein patch graft
CHAPTER 6: SPECIAL CASES 407
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6-7
Mild Carotid Stenosis with
Repeated Stroke (Japanese case)
Previously, randomized clinical trials such as NASCET have concluded that patients with mild carotid artery
stenosis (<50%) do not benet from CEA. However, as discussed in other sections of this book, the frequency of
patients with fragile plaque including a necrotic core or intra-plaque hemorrhage has been increasing rapidly
in recent years. These patients may have less than 50% stenosis but are refractory to the best medical treatment,
resulting in repeated TIAs or strokes. We perform CEA aggressively in such patients with repeated TIAs or ischemic strokes conned to the ipsilateral cerebral hemisphere despite the best medical treatment, including antiplatelet therapy. Clinical results of CEA for mild (<50%) carotid artery stenosis with unstable plaque on MRI are
quite satisfactory in our case series (1). Nowadays, we are conducting a multi-center observational study in Japan
to evaluate the clinical features, radiological nding, treatment strategy, and outcome in about 120 patients with
symptomatic, mild (<50%) carotid artery stenosis (Mild, but Unstable Stenosis of ICA; MUSIC study). The URL of
this study (UMIN000023635) is https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000027220.
Final results will be xed in December 2022.
The patient presented here is an 83-year-old man. He was admitted to our hospital because of right hemiparesis with sudden onset. Diffusion-weighted images showed a small, scattered infarct in the left hemisphere,
suggesting the occurrence of artery-to-artery embolism (A). Cervical MRA and 3D-CTA showed a relatively long
plaque with approximately 30% stenosis at the left ICA origin (B). Plaque MRI demonstrated high signal intensity on both T1-weighted images and time-of-ight (TOF) raw images, strongly suggesting a fragile, unstable
plaque with intra-plaque hemorrhage (C). Therefore, we decided to perform CEA on the left side. Intra-operative
observations revealed that the plaque contained a sludgy, muddy uid (D). CEA was safely performed without
any problem, and post-operative course was uneventful. On post-operative cervical MRA, the stenosis had completely resolved (E). Four years has passed since surgery without any recurrence of stroke.
408 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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CHAPTER 6: SPECIAL CASES 409
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410 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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CHAPTER 6: SPECIAL CASES 411
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6-8
Invasion of Inamed Plaque
into the Media and Adventitia
(Japanese case)
Although the frequently is not so high (maybe less than 1%), we may perform CEA for patients with the high
degree of inammation in the plaque causing the lesion to extend beyond the intima to the media and furthermore the adventitia. We believe that this area should be removed as completely as possible, because if left
untreated, it can be a source of post-operative embolization and a bed for restenosis. It is almost impossible to
predict it on pre-operative imaging and the operator must decide on a strategy intra-operatively.
This 65-year-old male was admitted to our hospital with a sudden onset of mild motor aphasia. On admission, diffusion-weighted images showed scattered small infarcts in the left frontal lobe (A). Cervical MRA showed
approximately 70% carotid artery stenosis; on plaque MRI, plaque showed a high signal on T1-weighted images
and was considered to be an unstable plaque (B). CEA was performed using the usual procedure. During surgery, we noticed that a part of the plaque lesion had inltrated into the media and the adventitia (C and D); after
removing the plaque as a single mass, the lesion extended to the media and adventitia was resected along with
the surrounding carotid artery wall (E). The defective portion of the carotid wall was repaired by suturing with
6-0 Prolene or 6-0 Preemio threads. The sutures were made along the direction of blood ow to prevent carotid
stenosis (F). The staining revealed that plaque lesions rich in inammatory cells reached into the adventitia (G).
After surgery, carotid stenosis completely resolved and no cerebrovascular events have occurred during 5 years
of follow-up.
412 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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CHAPTER 6: SPECIAL CASES 413
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414 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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CHAPTER 6: SPECIAL CASES 415
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Cervical Carotid Aneurysm
Associated with Marfan
Syndrome (Japanese case)
The incidence of cervical carotid aneurysm is not high, but we may have the opportunity to treat it surgically.
This 64-year-old woman was diagnosed with Marfan syndrome and dissecting aortic aneurysm. She was referred
to our department because pre-operative screening revealed an aneurysm in the right cervical ICA. A pulsatile
mass was palpated in the right mandible; 3D-CTA showed a marked tortuous extension of the right ICA, forming
a large aneurysm (A, arrows). We decided to resect this aneurysm and reconstruct the carotid artery. A skin incision, similar to carotid endarterectomy, was made in the right neck to expose the carotid artery. The aneurysm
was located medial above the hypoglossal and ansa cervicalis (B, arrow). The aneurysm was detached from the
surrounding tissue and pulled out in front of the operative eld (C, arrow). First, the CCA and the ICA distal to
the aneurysm were clamped with bulldog forceps, and then an external shunt was created by inserting a threeway shunt tube into each to avoid complications due to cerebral ischemia during the operation (D). Aneurysm
clips were then placed proximal and distal to the aneurysm and the aneurysm was resected. The proximal and
distal ends of the ICA were anastomosed in an end-to-end fashion using a 6-0 Prolene. Finally, the shunt tube was
removed and the incision was sutured to re-open the blood ow of carotid artery (E, arrow and D). (F) shows the
resected aneurysm. Post-operative course was uneventful, and post-operative 3D-CTA demonstrated that the
operated carotid artery was patent (G). She has experienced no recurrence of cervical carotid aneurysm for these
10 years after surgery.
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