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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3757_Библиотеки_им_академика_М_И_Перельмана.pdf
206
Fig. 18.3 Suturing of the
patch started at the apex
above the hypoglossal
nerve as it is retracted
inferiorly by silastic loop.
Arterial dilator in the distal
ICA controlling bleeding
and avoiding the
application of vascular
clamp to the distal ICA.A
suture line is started at the
lower end of the patch and
opened CCA
S. S. Hans
2. Retrojugular approach to ICA– The upper end of the incision is extended poste-
riorly behind the ear, and internal jugular vein is mobilized anteriorly (Fig.18.4).
Spinal accessory nerve is identied, and vagus nerve is mobilized anteriorly.
Hypoglossal nerve is not in the operative eld with use of retrojugular approach.
This enables distal exposure on the ICA.
3. For lesions extending to the junction of upper border of C2 and lower end of C1
(in patients not suitable for carotid stenting due to severe calcication), mandibular subluxation by an ENT surgeon/oral maxillofacial surgeon should be
considered. These patients should have a nasotracheal intubation instead of oraltracheal intubation if mandible subluxation is being planned. The mandible is
kept in place by a wire through the anterior nasal spine and through the mandible. In patients with a high plaque extending to the level of the upper portion of
the body of the C2 (following division of the posterior belly of the digastric), one
can palpate the tip of the styloid process which should be carefully removed by
a rongeur as the glossopharyngeal nerve is in close approximation to the styloid
process.
18 Carotid Endarterectomy forHigh Plaque
Fig. 18.4 Patch closure is
near completion with
dilator in place. Division of
post belly of digastric or
retraction of the posterior
belly of digastric and
stylohyoid for exposure of
distal ICA in patients with
high plaque
207
Intraoperative Carotid Stenting
If one is not certain about the end point of CEA, intraoperative carotid stenting
(CAS) should be considered. Some plaques are soft and feathery at its distal end
making the determination of their termination difcult during endarterectomy.Intraoperative CAS is performed by extending the lower end of the incision
toward the base of the neck with division of the inferior belly of the omohyoid.
Using a micropuncture technique 7 Fr. sheath is inserted into CCA just above the
base of the neck. A carotid/cerebral arteriogram is performed in the operating room
208
S. S. Hans
by injecting 8cc of diluted contrast through the sheath: using a 0.014mm guidewire
(CHOICE™ PT, Boston Scientic Corporation Marlborough, MA) and advancing
it under uoroscopy into the intracranial portion of the ICA and deploying a 6mm
× 4 cm self-expanding stent. Post angioplasty is performed by an appropriately
sized angioplasty catheter.
Chapter 19
Carotid Interposition Graft
SachinderSinghHans
Indications for carotid interposition grafting include:
(A) Locally advanced head and neck cancer involving the carotid artery
(B) Infected patch graft following carotid endarterectomy (CEA)
(C) Failed endovascular therapy for restenosis following CEA or carotid artery
stenting (CAS)
(D) Resection for extracranial carotid aneurysm when end-to-end anastomosis is
not feasible
(E) Carotid artery trauma when local repair is not feasible
(F) Carotid stenosis secondary to neck radiation
The conduit used for carotid interposition grafting (CIG) includes either straight
or a tapered PTFE graft (WL Gore, Newark DE). In contaminated elds, autogenous reconstruction with a greater saphenous vein (GSV) or supercial femoral
artery (SFA) can be used. The SFA should be evaluated by duplex imaging and is
preferred in patients undergoing resection of head and neck cancer invading the
carotid artery. Failed CAS often occurs in patients with heavy calcied plaque burden or due to structural failure of the stent. Removal of the stent along with the
resection of distal common carotid artery (CCA) and proximal internal carotid
artery (CIA) is followed by CIG.
S. S. Hans (*)
Vascular and Endovascular Services, Henry Ford Macomb Hospital,
Clinton Twp, MI, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
S. S. Hans et al. (eds.), Primary and Repeat Arterial Reconstructions,
https://doi.org/10.1007/978-3-031-13897-3_19
209
210
S. S. Hans
Carotid Interposition Graft forFailed Carotid Stenting
Carotid interposition graft for failed carotid stenting often requires exposure of the
distal end of the stent in the ICA.This exposure may be difcult if the cephalad end
of the stent extends above the level of the body of the second cervical vertebrae.
The operative intervention should be performed under general anesthesia. It is
important that any monitoring equipment does not obstruct the potential radiological imaging of the stent in the ICA in the event intraoperative imaging is necessary.
The operative dissection is usually more difcult than the standard CEA because of
the scar tissue in the area and the inammatory response due to the presence of the
stent. Sharp dissection with a 15-blade scalpel keeping the angle of the blade
slightly more horizontal and nding a plane very next to the adventitia of the common and internal carotid artery as well as the external carotid artery (ECA) is
necessary (Fig.19.1). Exposure of the distal ICA is like the one described in the
chapter of CEA.We prefer EEG monitoring as well as median nerve-evoked potentials to determine the need for shunt in patients who do not tolerate carotid cross
clamping.
Carotid stent
19 Carotid Interposition Graft
211
Divided
occipital art
Int. jugular
vein
Fig. 19.1 Exposure of distal CCA, ICA and ECA in the neck. ICA has a previous stent
Interposition Graft Without Shunt
If the ephalad end of the stent extends above the second cervical vertebral body,
intraoperative balloon occlusion may be necessary to control the retrograde bleeding from the ICA.In systemic heparinization (100units/kg body weight), the CCA
is punctured with a micro puncture needle and using a microcatheter 7F sheath is
inserted in the CCA just above the base of the neck, and a 0.014mm choice PT wire
(Boston Scientic, Marlborough MA) is advanced into the ICA toward the base of
the skull. A number 3 Fogarty catheter over the wire is inated using a 50% diluted
contrast media (Fig.19.2). If the upper end of the stent is below the level of the
212
Distal balloon
7F˚ Sheath in
S. S. Hans
occlusion
distal CCA
Fig. 19.2 Distal Baloon occlusion of ICA with Baloon lled with contrast to obtain distal control
second cervical vertebral body, balloon occlusion is not necessary. Proximal clamp
is applied to CCA a few centimeters below the proximal end of the carotid stent.
Distal clamping of the ICA can be performed with careful mobilization of the ICA;
applying a vascular clamp, the ICA is divided with a 15-blade scalpel, a few millimeters below the upper end of the stent. The origin of the ECA is also divided, its
distal end is suture ligated with a 4-0 cardiovascular polypropylene suture, and the
proximal end of the CCA is divided above the proximal clamp. Balloon occlusion
19 Carotid Interposition Graft
213
catheter is deated and removed, and soft vascular clamp such as Yasargil clamp
(Scanlan Int., St Paul, MN) is applied. The distal anastomosis is performed rst, and
Yasargil clamp is released so that retrograde blood ow will aid in removing any
debris. The vascular clamp is then moved proximally just below the distal anastomosis (Fig.19.3). Proximal anastomosis is performed in an end-to-end fashion as
well with a running 6-0 cardiovascular polypropylene suture (Fig.19.4). In some
patients with discrepancy in the size of the CCA and the graft, an end-to-side proximal anastomosis may be considered.
Fig. 19.3 Distal
anastomosis of divided
ICA to the interposition
graft
Distal ICA
Divided ECA
Prosthetic graft
Internal jugular
vein
Divided cartoid
artery
Fig. 19.4 Proximal
anastomosis of the
interposition graft to
divided distal CCA
Sternocleidomastoid
214
apered PTFE
S. S. Hans
Shunt Placement
If the EEG and somatosensory median nerve-evoked potentials indicate cerebral
ischemia or if the stump pressure is less than 40mmHg (if EEG monitoring is not
available), an indwelling shunt should be inserted during the time of carotid cross
clamping. The distal end of the shunt is rst advanced in to the divided ICA; after
back bleeding lls the shunt, the proximal end of the shunt is then inserted into the
CCA.The interposition graft is then passed over another shunt (second shunt). The
rst shunt is removed, and the second shunt with the interposition graft around it is
inserted. A distal end to end anastomosis to the conduit (graft) is performed rst
followed by proximal anastomosis of the conduit (graft) to the divided CCA
(Fig.19.5). Before the proximal anastomosis is completed, the shunt is removed,
and suturing is completed. If any technical difculties are encountered during the
interposition graft operation, completion carotid arteriogram should be performed
by injecting the contrast via a 5F sheath inserted into the CCA and graft anastomosis. If any abnormal ndings are detected, those should be corrected before operation is completed.
Fig. 19.5 Tapered PTFE
graft with Carotid shunt
inside the graft in patients
showing cerebral ischemia
during carotid cross
clamping
T
graft over the
shunt
19 Carotid Interposition Graft
215
Complications
Most complications of CIG are like those of CEA.The incidence of cranial nerve
injury such as superior laryngeal nerve injury and glossopharyngeal nerve is greater
as cephalad exposure of the ICA in the neck is necessary.