Thyrocervical trunk-external carotid artery bypass for positional cerebral ischemia due to common carotid artery occlusion. Technical note

Medically refractory positional cerebral ischemia (PCI) and concomitant orthostatic hypotension associated with chronic common carotid artery (CCA) occlusion are rare. In this technical report, the authors describe an extracranial bypass in which the thyrocervical trunk was used as a donor vessel to treat three cases of CCA occlusion with PCI. Postoperatively, although orthostatic hypotension remained, ischemia-related symptoms resolved in all three patients and long-term graft patency was demonstrated. It is possible to treat cerebral ischemia due to CCA occlusion with extracranial bypass surgery. In these patients, the thyrocervical trunk proved to be a suitable donor vessel for the reconstitution of blood flow within the external carotid artery.     

Axillary-to-carotid artery bypass grafting for symptomatic severe common carotid artery occlusive disease

PURPOSE: Revascularization of the internal or external carotid arteries is occasionally indicated for symptomatic atherosclerotic common carotid artery occlusion or long-segment high-grade stenosis beginning at its origin. I report the outcome of axillary artery-based bypass grafts to the distal common, internal, or external carotid arteries. METHODS: Between 1981 and 1997, 29 axillary-to-carotid bypass grafting procedures were performed on 28 patients, 15 men and 13 women, with a mean age of 68 years. Indications were transient ischemia in nine patients, amaurosis fugax in four patients, completed stroke in six patients, and nonlateralizing global ischemia in nine patients. Twenty-three common carotid arteries were totally occluded, and six had long-segment stenosis of 90% or greater beginning at the origin. Saphenous vein grafts were used in 25 procedures, and synthetic grafts were used in four. Grafts were placed to 13 internal, eight distal common, and eight external carotid arteries. RESULTS: There were no perioperative deaths; one stroke occurred (3.4%). No lymphatic or peripheral nerve complications occurred. In a 1- to 11-year follow-up period (mean, 4.5 years), there were no graft occlusions, one restenosis of 50% or greater, and two restenoses of 70% or greater. The 1-year stenosis-free rate for 50% or greater stenosis was 93%, and the 5- and 10-year rates were 87%. No late ipsilateral strokes occurred. The 5- and 10-year survival rates were 64% and 28%, respectively. Coronary artery disease was the major cause of late mortality. CONCLUSION: Axillary-to-carotid bypass grafting for severe symptomatic common carotid occlusive disease is safe, well tolerated, durable, and effective in stroke prevention. There is a high late mortality rate because of coronary artery disease in patients with severe proximal common carotid occlusive disease.     

External carotid endarterectomy with internal carotid artery transposition flap angioplasty for symptomatic internal carotid artery occlusion

The external carotid artery is an important collateral pathway for cerebral perfusion when the internal carotid artery is occluded. After internal carotid artery occlusion, there is a definite risk of ipsilateral neurological events. The authors retrospectively examined their experience with endarterectomy of the external carotid artery for symptomatic internal carotid artery occlusion. Results based on the authors' experience and on historical data show external carotid endarterectomy to be a safe procedure. Obliteration of the cul-de-sac appears to be a very important factor in the prevention of reocclusion or recurrence of symptoms after external carotid endarterectomy. Use of the internal carotid artery stump for patching of the endarterectomized external carotid artery is both safe and effective in treating symptomatic internal carotid artery occlusion.     

Rupture of previously unruptured giant carotid aneurysm after superficial temporal-middle cerebral artery bypass and internal carotid occlusion

A 51-year-old woman with an unruptured giant aneurysm of the internal carotid artery was treated by gradual occlusion of the internal carotid artery in the neck combined with a superficial temporal artery to middle cerebral artery bypass graft. Visual field defects improved after the operation, and thrombosis of the aneurysm was confirmed by angiography and computed tomography. Nevertheless, a fatal hemorrhage occurred 34 days after the final turn of the Selverstone clamp. The possible mechanism of rupture of the apparently thrombosed aneurysm is discussed. There is a risk of rupture of the aneurysm as long as the aneurysmal lumen remains after proximal ligation, no matter how small it may be.     

Operative strategies in patients with symptomatic internal carotid artery occlusion

A 15-year experience with 98 patients who underwent extracranial artery reconstruction for symptomatic internal carotid artery occlusion is reviewed. Thromboendarterectomy of the occluded carotid artery resulted in unacceptably high mortality and morbidity rates, and long-term patency of the internal carotid artery was rarely achieved. Carotid endarterectomy on the side opposite the occlusion proved to be successful in relieving nonlateralizing symptoms of cerebral ischemia, whereas results were less encouraging in patients with focal symptoms in the hemisphere ipsilateral to the occlusion. External carotid artery reconstruction on the side of the occlusion was successful in relieving focal symptoms. Surgical treatment in patients with symptomatic internal carotid artery occlusion should be planned in each patient on the basis of symptoms and anatomic pattern.     

Femoro-internal carotid artery bypass for cerebral ischemia in takayasu's arteritis

In two patients with Takayasu's arteritis, severe cerebral ischemia was successfully treated by femoral to internal carotid artery bypass using a polytetrafluoroethylene (PTFE) graft through a subcutaneous tunnel. All of the arch branches were critically stenotic or occluded in both patients. The entire thoracic aorta was affected by the active inflammation process in one patient and there was marked calcification in the other patient. In these situations we hesitate to use the thoracic aorta as the donor site of bypass. Considering that Takayasu's arteritis affects the thoracic aorta and the proximal portions of its branches, the femoro-internal carotid artery bypass can be constructed without involving severely diseased vessels and can be expected to result in good cerebral revascularization.     

Transverse cervical artery bypass pedicle for treatment of common carotid artery occlusion: new adjunct for revascularization of the internal carotid artery domain.

OBJECTIVE: We present two cases of common carotid artery occlusion that were treated by vascular reconstruction using the transverse cervical artery. METHODS: Two patients with common carotid artery occlusion presented with transient ischemic attacks resulting from decreased cerebral blood flow on the affected side. Both patients underwent vascular reconstruction using the transverse cervical artery. The transverse cervical artery was anastomosed to the ipsilateral external carotid artery at its origin, as a pedicle graft. A superficial temporal artery-middle cerebral artery anastomosis was then performed. RESULTS: The postoperative courses were uneventful. The transverse cervical artery bypass grafts were patent, and cerebral blood flow increased to normal levels. CONCLUSION: Transverse cervical artery grafting provides a less tedious alternative to saphenous vein interposition grafting for revascularization of the internal carotid artery domain.     

External carotid endarterectomy in the treatment of symptomatic patients with internal carotid artery occlusion

In patients with internal carotid artery (ICA) occlusion, the external carotid artery (ECA) can be both a source of collateral flow and a pathway for emboli. We identified 11 patients with ICA occlusion and ipsilateral ECA stenosis who underwent ECA endarterectomy to determine its role in treating extracranial cerebrovascular disease. Follow-up ranged from 1–65 months, with a mean of 27 months. Seven of eight patients with unilateral disease remained symptom free. The eighth patient had recurrent symptoms that were subsequently diagnosed as hemi-Parkinsonism. Two of three patients with bilateral occlusive disease had developed non-hemispheric symptoms at 12 and 24 months, respectively; the third remains asymptomatic after extracranial-intracranial bypass. None of the seven patients who presented with amaurosis fugax had recurrent visual symptoms. ECA endarterectomy is a safe and effective operation in treating symptomatic patients with ICA occlusion, especially those with transient monocular blindness or unilateral occlusive disease. It is less effective in those patients who have diffuse bilateral occlusive disease.     

Clinical outcome of standard extracranial-intracranial bypass surgery in patients with symptomatic atherosclerotic occlusion of the internal carotid artery

Summary Objective. In this retrospective study we wanted to determine the role of cerebral revascularization in patients with symptomatic occlusive cerebrovascular disease. Special emphasis was put on subsequent cerebrovascular events, benefit in neurological functioning and bypass patency, as evaluated during the follow-up period.Methods. A total of 73 superficial temporal artery to the middle cerebral artery bypasses were performed on 67 patients from 1986–2000. All patients exhibited a symptomatic occlusion of the internal carotid artery verified by angiography. All patients in our group were refractory to medical treatment. 65 patients (69 bypasses) with a mean age of 61 years (range: 38–79 years) were followed up over an average time of 44 months (range: 1.5–150 months).Results. The peri-operative morbidity rate was 3% with no mortality. 55 patients (85%) had no further cerebrovascular events after surgery, and only 7 (11%) patients experienced another cerebrovascular event. 57 (88%) patients showed an improvement of symptoms after surgery and only 1 patient fared worse during the follow-up peroid due to a stroke he suffered two years after bypass surgery. 90% of all bypasses remained patent during the follow-up.Conclusions. Although bypass surgery for occlusive cerebrovascular disease is still controversial, our retrospective study suggests both an improvement of symptoms and signs and a risk-reduction for future cerebrovascular events after surgery.     

Extracranial internal carotid artery occlusion associated with ipsilateral cerebral glioblastoma

A case of left extracranial internal carotid artery occlusion, associated with ipsilateral parietal glioblastoma, is reported. The clinical and radiological aspects are discussed. The Authors stress the usefulness of a complete investigation in patients with symptoms of cerebrovascular insufficiency.     

Positional symptomatic occlusion of the internal carotid artery: evaluation and surgical management

A 42-year-old woman developed right arm and right leg weakness when turning her head to the left. A carotid angiogram, in the neutral position, demonstrated anterior deviation of the left internal carotid artery and complete occlusion of the left internal carotid artery when the head was rotated to the left. During surgery, our patient had redundant left internal carotid artery and was treated by resection and reanastomosis of the internal carotid artery. The patient's Doppler 4 months postoperatively showed widely patent arteries, and she has subsequently been asymptomatic.     

External carotid artery angioplasty and stenting to augment cerebral perfusion in the setting of subacute symptomatic ipsilateral internal carotid artery occlusion. Case report

The authors performed external carotid artery (ECA) angioplasty and stenting in a 45-year-old man who had presented with right hemispheric crescendo ischemic symptoms stemming from acute right internal carotid artery occlusion (ICAO). This unique application of ECA angioplasty and stenting augmented cerebral perfusion and improved clinical symptoms. In certain situations, ECA stenting can increase cerebral perfusion in the setting of ICAO and ECA stenosis. The authors are the first to describe this approach in this context.