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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3710_Библиотеки_им_академика_М_И_Перельмана.pdf
Redo Carotid Endarterectomy
forRecurrent Atherosclerotic
Carotid Stenosis
42
History andPhysical Examination
A 63-year-old male had undergone bilateral
carotid endarterectomy in the past. Patient had
undergone left carotid endarterectomy with
Dacron patch 12years ago for high-grade stenosis of the left internal carotid artery. Following
left carotid endarterectomy (2007), patient was
lost to follow-up and presented to the hospital in
December 2015 with symptoms of transient ischemic attack (transient weakness and numbness of
the left upper extremity). Carotid duplex study
and CT angiography of the neck showed severe
stenosis (80% of right internal carotid artery) and
contralateral internal carotid artery occlusion
(Fig. 42.1). Medical comorbidities included
hypertension, nicotine abuse (80 pack years), and
recent history of bladder cancer. He had a coronary stent placed in 1997. Patient underwent
carotid duplex study and CT angiography of the
neck in September 2019 which showed irregular
mural plaque in the distal portion of the common
carotid artery narrowing the lumen to 75% transverse diameter (Fig.42.1).
Procedure
Patient underwent redo carotid endarterectomy
on September 21, 2019, under general anesthesia. There was evidence of severe ulceration in a
markedly stenosing plaque with platelet throm-
bus in the distal common carotid artery and
proximal internal carotid artery (Fig.42.2). The
plaque was removed, and copious irrigation was
performed. Distal internal carotid artery admitted number 5 Pilling dilator. No attempt was
made to separate intima from the remaining arterial wall as it was rmly adherent. The incision
was made in the middle of the bovine pericardial
patch which was applied at the index operation
in 2015. A bovine pericardial patch was sutured
with 5-0 cardiovascular polypropylene (Ethicon)
suture (Fig. 42.3). At the origin of the internal
carotid artery, the previously placed patch was
removed. A JP drain was inserted which was
removed on the rst postoperative day. Patient
was discharged the following day after endarterectomy in satisfactory condition with no postoperative complications.
Discussion
Recurrent carotid stenosis following carotid endarterectomy can be categorized into three different types: (A) residual disease, (B) early recurrent
stenosis (myointimal hyperplasia), and (C) late
recurrent stenosis (usually atherosclerotic).
Kumar et al. reported a form of meta-analysis
restenosis rate of 5.8% over a mean period of
47 months [1]. Restenosis that develops within
the rst 24months of carotid endarterectomy is
most commonly due to myointimal hyperplasia.
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_42
177
178
42 Redo Carotid Endarterectomy forRecurrent Atherosclerotic Carotid Stenosis
Fig. 42.1 CTA showing recurrent carotid stenosis
This lesion is the result of smooth muscle cell
proliferation, and it manifests as a concentric
smooth/brotic thickening rmly adherent to the
arterial wall. This lesion has a very low embolic
potential, but pre-occlusive lesions caused by
myointimal hyperplasia can result in acute thrombosis with potential of a neurological decit.
Progression of the lesion is slow in hyperplastic
restenosis. Restenosis may occur at the site of
application of vascular clamps referred to as
“clamp trauma.” After 24months, late recurrent
stenosis is often due to recurrent progressive or
de novo atherosclerotic lesions. Management
options to recurrent carotid stenosis include (A)
continuous surveillance with medical treatment,
(B) redo carotid endarterectomy/interposition
grafting, and (C) carotid artery stenting [2].
Tu et al. reported from a meta-analysis that
cranial nerve injury and myocardial infarction
were increased in the redo endarterectomy group
though cranial nerve injury is often reversible [3].
Patient undergoing carotid artery stenting are
more likely to develop restenosis than those
treated with redo carotid endarterectomy over a
long-term follow-up. Approach to the management of recurrent carotid stenosis should be
References
Fig. 42.2 Operative pictures showing recurrent plaque with ulceration in distal common carotid artery and proximal
internal carotid artery
179
Fig. 42.3 Redo left carotid endarterectomy with bovine
pericardial patch
based on plaque morphology, location of the
lesion, associated medical comorbidities, and
anticipated life expectancy. In this patient, with
location of the friable atherosclerotic lesion in
the distal common carotid artery and very proximal portion of the internal carotid artery. Redo
carotid endarterectomy was preferred to carotid
artery stenting in this patient as the lesion was
severely ulcerated and located primarily in the
accessible segment of the common carotid artery.
References
1. Kumar R, Batchelder A, Saratzisa A, AbuRahma AF,
etal. Restenosis after carotid intervention and its relationship with recurrent ipsilateral stroke: a systemic
review and meta-analysis. Eur J Vasc Endovasc Surg.
2017;57:766–75.
2. Rubin JR, Rits Y. Natural history and contemporary management of recurrent carotid stenosis. In:
Hans SS, editor. Extracranial carotid and vertebral
artery disease – contemporary management. Cham:
Springer; 2018. p.159–66.
3. Tu J, Wang S, Huo Z, Wu R, etal. Repeated carotid
endarterectomy versus carotid artery stenting for
patients with carotid restenosis after carotid endarterectomy. Surgery. 2015;157:1166–73.
Carotid Interposition Graft
inaPatient withPrior Carotid
Stenting forAcute Stroke
43
History andPhysical Examination
A 67-year-old female presented to the emergency
room of her local hospital with right sided facial
droop, difculty with nding words, and right
upper extremity weakness (NIH stroke scale 9)
on March 5, 2017. Medical comorbidities
included hypertension, type II diabetes mellitus,
and nicotine abuse. She was transferred to a tertiary care center and underwent unenhanced CT
scan of the head and CT perfusion study. In addition, she underwent CTA scan of the head and
neck which showed high-grade stenosis (> 90%)
of the left internal carotid artery and a moderate
stenosis (70%) of the right internal carotid artery.
There was complete occlusion of left M-1 segment at its origin (middle cerebral artery). In
addition, there was narrowing and irregularities
of the left A-1 segment of the anterior cerebral
artery.
Procedure
Patient underwent Trevo embolectomy of the left
middle cerebral artery. Left carotid stent was
deployed (Acculink-Abbott) with distal protection device using Spider X. At the completion of
intervention, patient had TICI 3 ow. There was
evidence of mild stenosis distal to the stent on
the completion arteriogram. Neurological decit
completely resolved in the ensuing few weeks.
Patient was seen in the ofce in 2019; a carotid
duplex study showed a high-grade stenosis of the
left internal carotid artery distal to the stent
(80%) and severe in-stent stenosis. Stent was
visualized in the distal common carotid artery,
and calcic stenosis was present, distal to the
stent at the origin of the left internal carotid
artery. She underwent CT angiography which
conrmed ndings of carotid duplex study
(Fig.43.1).
Patient was scheduled to undergo carotid
interposition grafting with removal of the carotid
stent and the distal common carotid artery. Under
general anesthesia with EEG monitoring and
median nerve evoked potential monitoring,
patient underwent resection of the distal 4cm of
the common carotid artery and proximal 2cm of
the internal carotid artery and a tapered PTFE
graft (7 × 4mm) which was cut in a manner that
the distal end of the graft was 5mm. This graft
was interposed between the divided common
carotid artery and internal carotid artery, and
external carotid artery was suture ligated
(Figs.43.2, 43.3, 43.4, and 43.5). Patient was dis-
charged on postoperative day 1 in satisfactory
condition.
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_43
181
182
43 Carotid Interposition Graft inaPatient withPrior Carotid Stenting forAcute Stroke
Fig. 43.1 CTA showing in-stent stenosis and severe nar-
rowing of the proximal internal carotid artery
Fig. 43.2 Operative picture of exposed carotid
bifurcation
Fig. 43.3 Resection of the common carotid artery and
internal carotid artery indwelling the stent
Fig. 43.4 Operative specimen indwelling the stent
Discussion
For carotid in-stent stenosis, repeat endovascular
therapy (balloon angioplasty with a drug eluting
balloon or repeat stenting) or carotid
endarterectomy with vein patch graft is the initial
treatment option [1]. A patient who fails carotid
artery stenting, because of heavy calcic burden
References
Fig. 43.5 Interposition graft distal to the common carotid
artery/proximal internal carotid artery
at the carotid bifurcation, recurrent in-stent stenosis, or structural failure of the stent, may be
best managed by resection of the distal common
carotid artery including the stent and interposition grafting between the common carotid artery
and proximal internal carotid artery. CT angiography of the neck and head should be performed
to determine the cephalad extension of the stent.
If the stent extends at or above the level of C2
vertebral body, additional exposure of the distal
internal carotid artery in the neck is necessary.
Balloon occlusion of the internal carotid artery
by placing a small Fogarty (number 3) over a
0.14 wire can be advanced with 7F sheath placed
in the common carotid artery at the base of the
neck. This will help obtain the distal control of
the internal carotid artery. If EEG and somatosensory median nerve evoked potentials indicate
cerebral ischemia or the stump pressure is below
40mmHg, an indwelling shunt is recommended.
The distal end of the shunt is rst advanced into
the divided internal carotid artery; after there is
183
back bleeding from the shunt, the proximal end
of the shunt is inserted into the common carotid
artery. The interposition graft is then placed over
another shunt (second shunt); the rst shunt is
removed, and the second shunt with the interposition graft around it is inserted [2]. Distal endto-end anastomosis is performed rst followed
by proximal anastomosis to the divided common
carotid artery. Before proximal anastomosis
completed, the shunt is removed, and the suturing
is completed.
In this patient, the carotid stent placement at
the index procedure did not cover the proximal
internal carotid artery where the disease was
present and as such of the progression of the
disease at the common carotid artery (80%) was
the indication for repeat endovascular therapy,
repeat carotid endarterectomy, or carotid interposition grafting. Various factors that determine the
type of secondary intervention include anticipated neck “hostility” level of recurrent lesion,
patient’s overall health, and anticipated life
expectancy. In addition, the open and endovascular operative skill sets of the treating surgeon
need to be considered when determining the best
approach for a patient.
References
1. Rubin JR.Redo carotid endarterectomy. In: Hans SS,
Shepard ED, Weaver MR, Bove PG, Long GW, editors. Endovascular and open vascular reconstruction:
a practical approach. Boca Raton: CRC Press; 2018.
p.149–52.
2. Hans SS, Gassner M.Carotid interposition grafting.
In: Hans SS, Shepard ED, Weaver MR, Bove PG,
Long GW, editors. Endovascular and open vascular
reconstruction: a practical approach. Boca Raton:
CRC Press; 2018. p.153–6.
Carotid Endarterectomy
inaPatient withRecent Minor
Stroke DuetoUnstable High
Plaque
44
Physical Examination andHistory
A 68-year-old male presented to emergency room
with weakness of left upper and lower extremity
which lasted for few hours. Medical comorbidities included hypertension and nicotine abuse.
Carotid duplex imaging and CTA of the head and
neck showed 80% stenosis of the right internal
carotid artery. The distal end of the plaque
extended to the middle of the second cervical vertebral body (Fig.44.1). MRI of the brain showed
ischemic infarct in the right parietal and occipital
lobe on diffusion scan. Patient was seen by stroke
neurologist, and his NIH stroke scale was 4.
Procedure
Patient underwent right carotid endarterectomy
under general anesthesia with EEG and median
nerve evoked potential monitoring. The cephalad
end of the incision was extended near the lobule of
the ear, and the tail of the parotid gland had to be
exposed and mobilized upward for exposure. In
order to obtain distal control of the internal carotid
artery, sternocleidomastoid branch of the occipital
artery and the occipital artery itself was ligated and
divided. Posterior belly of the digastric was divided
as well. Following systemic heparinization, carotid
artery was clamped, and external carotid artery was
looped with double vessel loop. Arteriotomy incision revealed that there was an 80–90% stenosis
with unstable plaque (severe stenosis with ulceration and intraplaque hemorrhage). Endarterectomy
was performed in a usual manner; no tacking
sutures was used as the end point of the endarterectomy was smooth and tapered off as a feathery end.
A bovine pericardial patch was applied (Fig.44.2).
Completion carotid arteriogram showed satisfactory (Fig. 44.3) endarterectomy site with normal
lling of the anterior cerebral artery, middle cerebral artery, and their branches. Postoperative course
was uneventful except for the weakness of the lower
lip (Fig.44.4) due to stretch injury to the marginal
mandibular branch of the facial nerve. At 1-month
follow-up, carotid duplex study did not show any
evidence of abnormalities of endarterectomy site.
At 3-month follow-up, right lower lip weakness had
completely resolved.
Discussion
Patient with recent stroke and high plaque represents a treatment dilemma for the vascular surgeon for the best treatment modality. Patient can
be managed with (1) carotid endarterectomy or
(2) carotid angioplasty/stenting. The results of
stenting versus endarterectomy for treatment of
carotid artery stenosis (CREST 1 trial) in 2502
patients over 10years of follow-up showed that
there was no signicant difference in the estimated 4-year rates of primary end point between
the stenting group and endarterectomy group
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_44
185
186
Fig. 44.1 Showing severe stenosis of the right internal carotid artery with high plaque
44 Carotid Endarterectomy inaPatient withRecent Minor Stroke DuetoUnstable High Plaque
Fig. 44.2 Completed carotid endarterectomy with bovine
patch divided post belly of digastric is seen
(7.2% and 6.8%, respectively) [1]. Periprocedural
rates of death were similar in both groups for
stroke (4.1% versus 2.3%, p=0.01) and for myocardial infarction (1.1% versus 2.3%, p=0.03).
Cranial nerve injury occurs in 4.6–8.6% of
patients undergoing carotid endarterectomy and
is usually transient with full recovery of function
in most patients in the ensuing few weeks. In a
5-year observational study, Chisci etal. reported
a 2.3% incidence of cranial nerve injury. All
Fig. 44.3 Completion carotid arteriogram
patients were evaluated by a neurologist before
and after endarterectomy [2]. The most common
nerve injury reported by the authors was marginal mandibular branch of facial followed by
the hypoglossal, vagus, and spinal accessory
nerve. In patients with high plaque, glossopharyngeal nerve injury may occur as the dissection
References
Fig. 44.4 Right lower
lip weakness from injury
to marginal mandibular
branch of facial nerve
with incision line near
the lobule of the ear
187
proceeds cephalad toward the stylohyoid, the
gastric muscle, and the tip of the styloid process
[3]. Injury to marginal branch of mandibular
leads to weakness of the corresponding lower
lip, injury to vagus nerve results in hoarseness,
injury to hypoglossal nerve causes deviation of
the tongue toward the ipsilateral side, and injury
to glossopharyngeal nerve leads to sensory loss
in the posterior one third of the tongue with difculty in swallowing. Association of cervical
hematoma with use of dual antiplatelet therapy
has also been associated with cranial nerve
injury. Other causes of cranial nerve injury
include excessive retraction, clamp injury, rarely
due to transection of the cranial nerve.
Occasionally, hypoglossal and vagus nerves may
have abnormal anatomical course and thus
become prone to injury. In patients undergoing
endarterectomy for high plaque, the incidence
for cranial nerve injury is higher as compared to
patients with non-high plaque.
References
1. Brott TG, Hobson RW, Howard G, Roubin GS,
et al. Stenting versus endarterectomy for treatment
of carotid artery stenosis. N Engl J Med. 2010;363:
11–23.
2. Chisci E, Rehring TF, Pigozzi C, Colon S, et al.
Cranial nerve injury is associated with dual antiplatelet therapy use and cervical hematoma after
carotid endarterectomy. J Vasc Surg. 2016;64(4):
985–9.
3. Vang S, Hans SS.Carotid endarterectomy in patients
with high plaque. Surgery. 2019;166(4):601–6.
Part XI
Aorto-Femoral Grafting