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Part X
Carotid Endarterectomy
Infected Dacron Patch Following Carotid Endarterectomy
34
History andPhysical Examination
A 76-year-old female was referred by a staff vascular surgeon for a persistent sinus in the right
neck (Fig.34.1) in February 2007. She had undergone right carotid endarterectomy in September
of 2006 for asymptomatic high-grade internal
carotid stenosis (80%). Comorbidities included
stable coronary artery disease, hypertension, and
Type II diabetes mellitus. Review of the operative
records revealed that the patient had Dacron patch
grafting at the time of carotid endarterectomy.
The patient’s immediate postoperative course was
uneventful; however she presented with a neck
mass with gradual enlargement. The mass measured 2 × 3cm and was rm in the midportion of
the carotid endarterectomy scar.
Fig. 34.1 Sinus in the right neck
Procedure
She was referred by the vascular surgeon to an
ear, nose, throat specialist who drained the mass
under general anesthesia. A slightly bloody/purulent drainage indicative of abscess was detected.
Drainage was performed and a Penrose drain was
left in place. The patient continued to have
drained sinus in the neck without any response to
systemic antibiotics.
She was re-explored by the same ENT sur-
geon in July of 2008. The dissection extended
near the carotid bifurcation, after the curettage of
granulation tissue, the incision was closed, and
the patient was referred for deformative management. The patient was seen in the outpatient
clinic in February 2009 (Fig.34.1). A CTA of the
neck showed inammatory mass around the origin of the internal carotid artery (Fig.34.2).
Under general anesthesia with EEG monitor-
ing and systemic (intravenous antibiotics), the
patient was re-explored along the previous scar
tissue, and around the sinus an elliptical incision
was made. The sternomastoid muscle was
retracted laterally, and silastic vessel loop was
placed around the common carotid artery above
the base of the neck. Seven thousand units of
heparin were administered intravenously by the
anesthesia. In the cephaloid portion of the dissection, the posterior belly of the digastric muscle
was divided. Carotid stump pressure was measured 70mm Hg, and common carotid clamping
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_34
145
146
Fig. 34.2 CTA showing
mass around the carotid
bifurcation
Fig. 34.3 Operative picture of the carotid bifurcation
34 Infected Dacron Patch Following Carotid Endarterectomy
did not result in any change in EEG.Hypoglossal
and vagus nerves were carefully separated from
the inammatory mass (Fig. 34.3). The greater
saphenous vein was harvested by the right upper
thigh. The distal common carotid artery and
proximal internal carotid artery were resected
along with the inammatory mass. Inammatory
mass was surrounding the unincorporated Dacron
patch graft. The external carotid artery was
ligated. A non-reversed greater saphenous vein
interposition graft was used for arterial reconstruction with removal of the valves by
intussuscepting of the vein. Satisfactory healing
of the neck incision occurred in the ensuing
5–7days.
The patient underwent follow-up duplex
imaging which showed patent interposition graft,
3months and 9months following the interposition grafting. However, 1 year later (2010), the
patient underwent a carotid duplex imaging
which showed evidence of stenosis in the interposition graft, and this was conrmed by CT
angiography (Fig.34.4). The patient underwent
transfemoral carotid stenting (Fig.34.5) in 2010.
The patient developed in-stent stenosis in 2011
(Fig.34.6). Subsequently, the patient developed
asymptomatic stent thrombosis. The neck sinus
has completely healed, and the patient has
remained asymptomatic for the past 8 years without signicant stenosis in the left internal carotid
artery.
Discussion
Primary closure following carotid endarterectomy is seldom performed in contemporary vascular practice. Patch graft closure with autogenous
Discussion
147
Fig. 34.6 In-stent carotid stenosis
Fig. 34.4 CTA showing carotid interposition vein graft
stenosis
Fig. 34.5 Carotid stenting for carotid interposition vein graft stenosis
148
34 Infected Dacron Patch Following Carotid Endarterectomy
vein, PTFE patch, Dacron, and bovine pericardial
patches are commonly used. Infection in an
autogenous vein patch is extremely uncommon.
However carotid vein patch blowout has been
reported. Approximately 0.25–0.5% of all
Dacron patches appeared to get infected following carotid endarterectomy [1, 2]. Patch graft
infection may appear early or late and has a
bimodal distribution depending upon the virulence of the microorganism [1, 2]. Postoperative
wound hematoma is associated with late development of infection [1, 2].
Most patients present with neck swelling,
pseudoaneurysm, or a draining sinus along the
incision line. Following duplex imaging, CT
angiography of the neck is the investigation of
choice. Complete excision of all the infected
material and arterial reconstruction of the autogenous interposition vein graft are recommended.
In patients with a history of neck radiation
with unhealthy (poor vascularity) tissues over
the reconstructed vein graft, the sternomastoid
muscle ap or pectoralis major myocutaneous
ap should be considered.
Interposition vein graft has a tendency to
develop myointimal hyperplasia as often happens with arterial reconstruction using the
greater saphenous vein. Usually the site of
myointimal hyperplasia is at the site of the
valves as was present in this patient. Carotid
angioplasty/stent placement is an option for
this complication, but long-term results of
carotid stenting for carotid interposition graft
stenosis are not well dened.
References
1. Rockman CB, Su WT, Domenig C, Lamparello PJ,
etal. Post-operative infection associated with polyes-
ter patch angioplasty after carotid endarterectomy. J
Vasc Surg. 2003;38:251–6.
2. Knight BC, Tait WF. Dacron patch infection follow-
ing carotid endarterectomy: a systemic review of the
literature. Eur J Vasc Endovasc Surg. 2009;37:140–8.
Carotid Endarterectomy
foraRecent Minor Stroke
History andPhysical Examination
A 60-year-old male with a history of hypertension, hyperlipidemia, and nicotine abuse was
referred by his primary care physician to go to the
emergency room. While at work, the night before
admission, he developed numbness and clumsiness of the right hand. He also had some difculty
with hand coordination. He became slightly confused. A CT scan of the head was performed in
the emergency room which was unremarkable.
Carotid duplex study and CT angiography showed
high-grade stenosis (90%) at the origin of the
internal carotid artery (Fig. 35.1). MRA of the
brain showed multiple areas of ischemic infarcts
on the diffusion scan in the distribution of the left
middle cerebral artery (Fig.35.2).
35
Procedure
He underwent carotid endarterectomy under
cervical block anesthesia, 5 days after his initial
episode. His neurological decit was four (NIH
stroke scale) at the time of endarterectomy.
Arteriotomy incision in the common and internal carotid artery revealed severe stenosis with
ulceration and intraplaque hemorrhage with a
fresh thrombus in the internal carotid artery
(Fig.35.3). After a carotid Doppler, a left carotid
endarterectomy with bovine pericardial patch
was performed.
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_35
Fig. 35.1 CTA showing high-grade stenosis involving
origin of the left internal carotid artery
His postoperative course was uneventful, and
he was seen as an outpatient in 4 weeks’ time. A
follow-up carotid Doppler study showed no evidence of stenosis in the common or internal
carotid artery. His neurological function had
completely recovered. The patient underwent
coronary artery bypass graft in March 2019.
149
150
Fig. 35.2 MRI of the brain diffusion scan showing small
infarct in the distribution of the left middle carotid artery
Fig. 35.3 Thrombus removed from the internal carotid
artery at the time of carotid endarterectomy
Discussion
35 Carotid Endarterectomy foraRecent Minor Stroke
symptoms to 2 weeks) should be performed to
prevent a recurring stroke. In the beginning, there
was a tendency to wait 6 weeks for the infarct to
heal before recommending carotid endarterectomy to decrease the incidence of intracerebral
hemorrhage from hyperperfusion. However, it
has been well established that the perioperative
risk of early carotid endarterectomy in the presence of recent stroke is no greater than delayed
carotid endarterectomy. In addition waiting 6
weeks to perform carotid endarterectomy may
result in a second major stroke.
DeRango etal. [2] did perform meta-analysis on 47 studies reporting periprocedural
strokes/death after carotid endarterectomy and
carotid stenting related to the time between
qualifying neurological symptoms and intervention was performed. Of the 47 studies, 30
were on carotid endarterectomies, 7 were on
carotid artery stenting, and 5 included both
operations. DeRango et al. concluded that
carotid endarterectomy within 15 days from
stroke/transient ischemic attack can be performed with periprocedural stroke risk of less
than 3.5%. Carotid artery stenting within the
same period may carry a stroke rate of 4.8%.
From this data, it was quite apparent that carotid
revascularization can be safely performed
within the 1st week (within 0–7days symptoms
onset). However, in clinical practice, one should
wait 48–72 hours following recent stroke in
order to medically optimize the patient, and any
edema around the infarct improve before
carotid intervention is undertaken. In general,
these recommendations are based for minor to
moderate stroke (NIH stroke scale <15). Carotid
revascularization is usually not recommended
in patients whom the neurological decit is
severe (NIH stroke scale >15).
Early carotid endarterectomy after a recent transient ischemic attack in the distribution of corresponding middle cerebral artery has been the
standard of practice; however the role of early
carotid endarterectomy in the presence of recent
stroke has only been established in the last two
decades [1]. It has been shown by many authors
that early carotid endarterectomy (the onset of
References
1. Hans SS, Adro RJ, Catanescu I. Timing of carotid
endarterectomy after recent minor to moderate stroke.
Surgery. 2018;164:820–4.
2. DeRango P, Brown MM, Chaturvedi S, Howard VJ,
etal. Summary of evidence on early carotid interven-
tion for recently symptomatic stenosis based on meta-
analysis of current risks. Stroke. 2015;46:3423–36.
Carotid Endarterectomy
withMandibular Subluxation
History andPhysical Examination
A 69-year-old male has been followed as an outpatient for asymptomatic carotid stenosis. A
carotid duplex study performed in March of 2015
showed 80–99% stenosis of the right internal
carotid artery. He underwent CT angiography of
the carotid arteries (neck); the plaque was heavily
calcied and extended to the junction of C1 and
C2 (Fig.36.1). Since the plaque was heavily calcied, carotid artery stenting was thought to be
contraindicated. The patient underwent conventional catheter-based carotid and cerebral arteriography which showed severe stenosis of the
right internal carotid artery with the upper end of
the plaque extending to the junction of C1 and C2
vertebral body (Fig.36.2). It was decided to perform a carotid endarterectomy with mandibular
subluxation.
Procedure
36
Fig. 36.1 CTA showing 90% stenosis in the right internal
carotid artery with calcied plaque extending to upper C2
vertebral body
On March 19, 2015, the patient was taken to the
operating room and under nasotracheal intubation and EEG monitoring. The patient underwent
mandibular subluxation by the oral and maxillofacial surgeon. Two milliliters of 1% lidocaine
with one ratio 100,000 epinephrine was inltrated in the mucosa. The K-wire was passed
through the right body/parasymphysis region of
the right mandible. Attention was then turned to
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_36
the left piriform rim where another K-wire was
placed. Two 22-gauge wires were used to subluxate the mandible toward the left side. The condyle on the right side was subluxated from the
glenoid fossa and brought anterior to the articular
eminence. The two 22-gauge wires were tightened to secure the mandible in position.
Right carotid endarterectomy was carried out
in a usual fashion. Hypoglossal and vagus nerves
151
152
Fig. 36.2 Carotid arteriogram showing high plaque with
severe stenosis of the right internal carotid artery
Fig. 36.3 Satisfactory completion carotid arteriogram
via the superior thyroid artery
36 Carotid Endarterectomy withMandibular Subluxation
were preserved. Carotid clamping did not result
in any change in the EEG or somatosensory
evoked nerve potentials (median nerve).
Following completion of endarterectomy, completion arteriogram was obtained through a catheter inserted via the superior thyroid artery into
the common carotid artery (Fig.36.3).
The patient’s postoperative course was
uneventful. He was discharged on the second
postoperative day. He complained of some discomfort in the right side of the jaw in the preauricular area which subsequently improved over
the following 3 weeks. He has been followed
yearly and has not shown any evidence of recurrence of the right carotid stenosis or any neurological symptoms.
Discussion
During carotid endarterectomy, the distal end of
the plaque may extend cephalad for a considerable distance and will need higher than usual
exposure. This difculty in exposure may be
complicated by high carotid bifurcation in obese
patients with a “short neck.” With a high-quality
CTA (axial, coronal, and sagittal cuts with reconstruction), the relationship of the cephalad end of
the plaque in relation to the body of the cervical
vertebra can be determined. For practical purposes, the extracranial portion of the internal
carotid artery can be divided to three segments
(zones). The usual occasion of carotid bifurcation
is at the level of C3–C4 vertebral body, and
plaque extends to zone I (upper end of C3) in
most patients. Zone II extends from the upper end
of C3 to the upper end of C2, and typically high
plaque often extends to this level. Zone III is
when the cephalad end of the plaque extends
higher than C2 vertebral body which is quite
uncommon [1]. In some patients, CTA imaging
may fail to detect the distal feathery end of the
plaque, and high plaque may be an unexpected
nding during the performance of carotid
endarterectomy.
In most patients with high plaque, distal
exposure can be obtained by dividing the sternocleidomastoid branch of the occipital artery or
the occipital artery itself which helps in cephalad
mobilization of the hypoglossal nerve. The
hypoglossal nerve can be carefully retracted
upwards with a silastic vessel loop. In many
instances, venous tributaries are crossing this
area and should be carefully ligated and divided.
The posterior belly of the digastric muscle is
either retracted upward after its mobilization or
may have to be transected. In few patients where
the plaque extends up to the middle of or upper
end of C2 vertebral body, preoperative decision
should be made regarding mandibular subluxation. In such patients, carotid artery stenting is
References
153
a better option unless the plaque is heavily calcied as was present in this patient. In such
instances, an oral maxillofacial or an ENT surgeon should be consulted to perform mandibular
subluxation with nasotracheal intubation.
Subluxation of the mandibular condyle that
tends to 15mm anteriorly results in displacement of the mandibular ramus 20–30mm anteriorly [2]. This provides a marked increase in
the exposure of the internal carotid artery
extending to the base of the skull as the triangular operating eld is transformed into a rectangular eld [2]. Besides local discomfort after
the mandibular subluxation, there is increased
frequency of cranial nerve injuries which may
include recurrent laryngeal nerve and superior
laryngeal nerve marginal branch of the man-
dibular. Occasionally contralateral compression of the carotid sheath between the angle of
the mandible and transverse vertebral process
may occur and result in traumatic carotid artery
dissection. This can also result in contralateral
vagus nerve impingement.
References
1. Hans SS.Carotid endarterectomy for high plaque. In:
Hans SS, editor. Extracranial carotid and vertebral
artery disease – contemporary management. Cham:
Springer; 2018. p.147–50.
2. Fischer DF, Clagett GP, Parker JI, Fry RE, et al.
Mandibular subluxation for high carotid exposure. J
Vasc Surg. 1984;1:727–33.