Total in situ reconstruction of the internal carotid artery

Abstract

Carotid bifurcation lesions, and specifically atheromatous ulcers with their potential of embolization, can cause cerebral infarction and stroke. Carotid endarterectomy, since its introduction by DeBakey et al. in 1953, has become the procedure of choice for prevention of stroke [Moore WS (1993). Extracranial Cerebrovascular Disease: The Carotid Artery in Vascular Surgery, 4th ed. WB Saunders: Philadelphia, 533.] Although carotid endarterectomy can safely be performed without shunting, certain high-risk patients will require shunting in order to prevent perioperative stroke. If for any unforeseen reasons the carotid artery has to be replaced on patients who must have shunting, the carotid artery has to be clamped and the shunt removed either proximately or distally. A tube graft (vein or synthetic) has to be threaded over the shunt before the shunt is placed back in its original position. The process can be accomplished in a timely fashion or be delayed, thus setting the potential to compromise cerebral flow and increase the possibility of an ischemic event. In four patients who required shunting and needed reconstruction of the carotid artery, the in situ technique was used. The shunt was left in its original position, maintaining continuous cerebral flow throughout the operation. All four patients awoke after the surgery with no evidence of neurological deficit.