Treatment of carotid tandem stenosis by combined carotid endarterectomy and balloon angioplasty: technical case report.

OBJECTIVE AND IMPORTANCE: Cervical internal carotid artery disease associated with high-grade carotid siphon stenosis poses a therapeutic challenge. This report describes the combination therapy of carotid end-arterectomy and intraoperative transluminal balloon angioplasty of the carotid siphon. CLINICAL PRESENTATION: A 67-year-old man sustained repeated left hemispheric and retinal transient ischemic attacks. Results of a diagnostic examination, including angiography, disclosed a 70% ulcerative stenosis of the left extracranial internal carotid artery as well as a 90% stenosis of the left intracavernous carotid artery. The decision was made for combined open and endovascular therapy. INTERVENTION: After standard endarterectomy, an introducer for the dilation catheter was placed into the common carotid artery before final closure of the arteriotomy and recirculation. Under intraoperative fluoroscopy, a 3-mm dilation balloon was navigated into the carotid siphon stenosis and inflated several times. A 30% residual stenosis in the carotid siphon was obtained as a final result. The intervention was completed without complications. No further neurological symptoms were observed during the follow-up period of 30 months. CONCLUSION: Carotid endarterectomy, combined with intraoperative transluminal angioplasty of carotid siphon stenosis, is a feasible procedure for selected patients with carotid tandem stenosis.     

A case report of entrapment of PTCA balloon catheter caused by its rupture

This is a report of a rare case in which an angioplasty balloon catheter became entrapped within the lumen of the coronary artery after the balloon ruptured during percutaneous transluminal coronary angioplasty (PTCA). The patient was a 69-year-old man who underwent elective PTCA of the circumflex coronary artery (Cx) with USCI 2.5 mm new Probe. The inflation failed to dilate the lesion up to 18 bar; at this pressure, balloon rupture was observed. Any attempt to withdraw the balloon catheter across the lesion was not successful, and then the patient was transferred to the operating room for removal of the balloon catheter. After establishing cardiopulmonary bypass, an arteriotomy in the Cx confirmed that the balloon fragment had become entrapped at a sharp edge of calcific stenosis after balloon rupture. The entrapped catheter was successfully removed from the arteriotomy of the Cx, and coronary bypass grafting was performed to the left anterior descending artery which had restenosis after PTCA 3 months ago. The patient had an uneventful postoperative course and was discharged in excellent condition 30 days after surgery. The balloon rupture of PTCA had been considered a minor problem, however, as this case demonstrated, this seemingly benign complication may lead to potentially disastrous consequences.     

Spontaneous arteriovenous fistula of the external carotid artery treated by a detachable balloon--a case report

Spontaneous arterio-venous fistula (AVF) of the external carotid system is very rare. We successfully treated such a case by the detachable balloon method. The patient, a 2-year-and-9-month-old female who has no history of trauma had a pulsating mass at her right retroauricular region six months after birth. On admission to our clinic she was neurologically free except the pulsating mass (2 X 3 cm) with bruit and thrill. Selective right external carotid angiography revealed a high-flow simple AVF from internal maxillary artery to jugular vein. The normal blood flow of both the external and internal carotid system was decreased. Under local anesthesia, non-detachable balloon catheter was inserted to the internal maxillary artery by the transfemoral approach and inflated at the proximal side of the orifice of AVF until the vascular murmur in the neck disappeared. The balloon catheter was then exchanged with a detachable balloon catheter (Debrun, No. 9) which was inflated by silicone (0.4 ml), and was detached successfully. Follow-up angiography 1 year after the treatment revealed no recurrence of the fistula and almost branches of external carotid artery such as middle meningeal artery, occipital artery, superficial temporal artery and facial artery were clearly seen.     

Successful management of bilateral carotid-cavernous fistulae with a trans-sphenoidal approach.

A patient with traumatic bilateral carotid-cavernous fistulae was successfully treated by an entirely extracranial approach. The larger fistula on the left was exposed via a transethmoidal, trans-sphenoidal route and was directly opened and packed while the cavernous carotid artery was stented open by an intraluminal balloon catheter. The balloon catheter provided temporary hemostasis and was removed after the fistula had been packed. The left carotid artery remained patent, and the smaller fistula on the right was subsequently obliterated by a balloon catheter. The fistulae have remained cured, and the left internal carotid artery supplies the cerebral circulation.     

Balloon catheter tamponade in cardiovascular wounds

From 1980 to 1990, operative balloon catheter tamponade was used in 12 patients with cardiac or vascular injuries from penetrating wounds. In nine patients, a balloon catheter was passed into a bleeding site through a bullet track or proximal artery and inflated with saline or radiologic dye. In two of these patients, the proximal balloon catheter was folded on itself, tied in that position, and left in the patient permanently. In the other seven patients in this group, the balloon catheter was attached to a three-way stopcock and left temporarily inflated postoperatively. These patients were then observed in the intensive care unit for 3 to 4 days, at which time the balloon was withdrawn. Eight of nine patients survived without recurrent hemorrhage after removal of the balloon catheter, while one patient with a Fogarty balloon placed in the carotid siphon died of a cerebral infarction. Balloon catheter tamponade was also used on a temporary basis in one patient with a posterior cardiac wound and in one patient with an anterior stab wound of the inferior vena cava at the renal veins, whereas in two patients with high cervical arteriovenous fistulas, one had permanent placement of the balloon catheter while the other had temporary placement. One of the latter patients also had acute hemorrhage. Although all four patients survived, one of the patients with a fistula developed a recurrence and another required two separate operative procedures for correct placement of the balloon to cure the fistula.     

Coil embolization with a hyperform occlusion balloon for an acutely ruptured wide-necked basilar tip aneurysm: case report

A 54-year-old woman was admitted to our hospital because of severe headache. CT scan demonstrated subarachnoid hemorrhage (SAH), and cerebral angiography revealed a wide-necked basilar tip aneurysm with a bleb and a small basilar artery-left superior cerebellar artery aneurysm. She was treated with coil embolization using a neck remodeling technique one day after SAH. Guiding catheters were introduced into the bilateral vertebral artery via the transfemoral route. A Hyperform occlusion balloon catheter was introduced into the left posterior cerebral artery (PCA) through the left vertebral artery, and was placed at the neck of the basilar tip aneurysm for neck remodeling. Then, the microcatheter for coil deployment was placed in the dome of the aneurysm through the right vertebral artery. The coil was deployed in the aneurysm while the balloon was inflated across the neck. The inflated Hyperform occlusion balloon was partially herniated into the dome of the aneurysm. The distal part of the balloon was positioned in the left PCA segment, and its proximal part was positioned in the basilar artery. The balloon conformed easily to the aneurysmal neck and its surrounding vessel structure. When the balloon was deflated, the coil did not protrude into the parent artery, and was stable in the aneurysm. Angiography immediately after the procedure showed complete occlusion of the aneurysm with patency of both PCAs. The Hyperform occlusion balloon is very compliant and supple, so it easily changes from its cylindrical shape when inflated to expand into the origin of the arterial branches emerging from the aneurysm neck. We think this balloon is a useful device for treating wide-necked aneurysms located at arterial bifurcation.     

A safe technique for the precise localization of carotid-cavernous fistula during balloon obliteration. Technical note

The authors report a technique to precisely localize a fistulous opening in the carotid artery. The patient is heparinized and a Prolo catheter is introduced into the internal carotid artery and inflated distal to the approximate site of the fistula. Heparinization allows the balloon to be inflated long enough to obtain and analyze high-quality angiography film without fear of thromboembolism generated by the temporary balloon occlusion. Contrast material injected through the Prolo catheter proximal to the balloon reveals a small segment of cavernous carotid artery between the inflated balloon distally and the fistula proximally. The venous structures are now only faintly opacified and cannot obscure the morbid anatomy of the exact fistulous tear in the carotid artery. If the balloon is placed exactly opposite to the site of the fistula, a standing, stagnant column of dye forms a cast of the cavernous, petrous, and cervical carotid artery. Once the fistula is localized with this method, it may be obliterated by any therapeutic means preferred. If the Prolo catheter is used for intraluminal occlusion, then a transfemoral contralateral carotid angiogram is done before the heparin is reversed to confirm that the balloon has not been placed proxial to the fistula.     

Surgical treatment of the aged patient with patent ductus arteriosus

A 62-year-old woman with massively calcified patent ductus arteriosus (PDA) associated with severe pulmonary hypertension and bilateral hydronephrosis was successfully operated upon. At first, percutaneous nephrostomy was performed under ultrasonographic guidance. Two weeks later, PDA was repaired under cardiopulmonary (CP) bypass, since its division through a left thoracotomy was considered to be fraught with danger. A Foley's balloon catheter was inserted into the aorta through the ductus after a pulmonary arteriotomy under CP bypass. The ductus was closed simpler and safer with a patch mounted on the catheter, because blood flow from the aorta was well controlled by the inflated balloon catheter.     

Retrograde carotid stenting for isolated stenosis of the proximal common carotid artery--case report

A 49-year-old female with a history of systemic hypertension and diabetes mellitus suffered transient right hemiparesis. Carotid angiography with arch-aortography detected severe stenosis of the proximal portion of the left common carotid artery. The left carotid bifurcation was surgically exposed and retrograde catheterization was performed to approach the proximal common carotid artery stenosis. The lesion was dilated with a balloon catheter and successfully stented without complications. The left internal carotid artery was clamped during the procedure to avoid embolism. Retrograde carotid stenting for stenosis of the proximal common carotid artery is a safe and effective alternative to conventional surgery in selected patients.     

Effect of force on anastomotic suture line disruption after carotid arteriotomy

Static and dynamic forces exerted on 6-0 polypropylene suture material after carotid arteriotomy were measured in 22 adult mongrel dogs. Force was measured in 11 normotensive animals (Group I) before and 6 weeks after carotid artery repair. Force was measured in the remaining animals during normotension and induced hypertension before and 6 weeks after operation. The tensile strength of each suture used in the study was measured by the manufacturer. The mean force required to break a 6-0 polypropylene suture measured 436.9 +/- 2 g, whereas knotting of the suture decreased the tensile strength to 316.9 +/- 3.9 g (p less than 0.001). The static and dynamic axial forces exerted on the suture after carotid arteriotomy in Group I was in the range of 26 g and decreased to 18 g at 6 weeks, whereas the 45 degree force exerted during the static dynamic phase measured in the range of 23 g and decreased to 16 g at 6 weeks (not statistically significant). The axial and 45 degree forces exerted on 6-0 polypropylene suture material in Group II under normotensive conditions were in the range of 14 g after carotid arteriotomy and ranged between 12 to 14 g at 6 weeks. Systolic hypertension did not result in a significant increase in axial or 45 degree forces during static or dynamic measurements, both in the range of 15 g after carotid arteriotomy. Measurements were similar at 6 weeks and ranged between 14 and 16 g. Our data indicate that 6-0 polypropylene suture material is an appropriate choice for repair of the carotid artery and that the suture material has sufficient inherent tensile strength to withstand forces generated in the neck region. Furthermore, our data indicate that spontaneous carotid artery suture line disruption is most likely related to damage to the suture strand during carotid artery repair rather than an inherent weakness in the suture material.     

Mitral valve re-replacement in a patient with occlusion of the left internal carotid artery

An 83-year-old female patient, who had previously undergone mitral valve replacement using bioprosthesis at 15 years ago, presented symptoms of congestive heart failure. Mitral valve regurgitation was caused by structural deterioration of the bioprosthetic valve, and replacement of the bioprosthesis was indicated. Digital subtraction angiography revealed occlusion of the left internal carotid artery, which put this patient at high risk to cerebral complications during heart valve surgery. Administration of acetazolamide induced a marked decrease in the blood flow in the left cerebral hemisphere. Re-replacement of the mitral valve was successfully performed under high-flow cardiopulmonary bypass. Intra-aortic balloon pumping produced pulsatile blood flow with a peak pressure of 90-100 mmHg during the cardiopulmonary bypass. She recovered after surgery with no neurological complication. We believe the pulsatile cerebral perfusion produced by the intra-aortic balloon pumping with high-flow cardiopulmonary bypass was effective for preventing cerebral complications in this patient with internal carotid artery occlusion.     

Treatment of carotid-cavernous sinus fistula by the balloon technique combined with a by-pass procedure using a vein graft-technical note note

A case with spontaneous carotid-cavernous fistula treated by balloon catheter technique combined with a extra-intracranial by-pass using a saphenous vein graft between the common carotid artery and the middle cerebral artery is reported. A 72-year-old female was admitted with complaints of recurrent symptoms of carotid-cavernous fistula 4 months after spontaneous remission. Angiograms showed the presence left internal carotid-cavernous sinus fistula. Poor cross-filling from the right internal carotid artery to the territory of the left internal carotid artery via the hypoplastic right A1 and left posterior communicating artery was also observed. Symptoms such as chemosis, exophthalmos and visual disturbance gradually progressed during the hospitalization. A common carotid-middle cerebral artery anastomosis was performed with a saphenous vein graft and the carotid cavernous fistula was occluded directly with a balloon catheter. The blood flow via the graft, cortical blood flow, cortical tissue O2 and CO2 were continuously measured during the operation. After the internal carotid artery occlusion, sufficient blood flow via the graft and no significant changes of the cortical blood flow, cortical tissue O2 and CO2 were observed. The postoperative angiogram showed that the by-pass was patent and all branches of the left internal carotid artery were filled via the by-pass. The postoperative course was uneventful and the progressive symptoms improved except for visual disturbance on the left. She is in good condition one year after the operation. The usefulness of this surgical procedure with monitoring of cerebral blood flow and metabolism during operation is also discussed.     

A case of carotid occlusive disease treated with stenting for recurrence of stenosis: strategy on intolerance to temporary occlusion

Carotid artery stenting has emerged as an acceptable treatment alternative in patient with occlusive carotid bifurcation disease. High-risk surgical candidates have a lower rate of morbidity after carotid artery stenting with distal embolic protection. Among distal protection devices, a Guardwire balloon occlusion is the most frequently employed in Japan. A 79-year-old male who had severe stenosis at the origin of left carotid artery was treated with stenting under Guardwire balloon protection. He was intolerant to carotid artery occlusion and endovascular procedures were performed under intravenous anesthesia or general anesthesia. In addition, he suffered recurrent stenosis seven months after the first procedure and 16 months after second procedure, and underwent repeated intervention. It was considered that the long tortuous lesion was a cause of the recurrent stenosis.     

Surgical management of a ruptured aneurysm of the common carotid artery--case report

A case report on 80-year patient ruptured aneurysm of the common carotid artery (CCA), immediately below its branching which leading to pulsatile mass on the neck. Fifteen days later skin perforation and external hemorrhage ensued. The diagnosis was established by clinical examinations, ECHO duplex scan US, arteriography of carotid arteries and CT of the neck (cervical CT). The patient underwent emergency surgical procedure in general endotracheal anesthesia. The approach to the rupture site was hindered by the massive hematoma and thus CCA, ICA and ECA were trapped. Arteriotomy of ICA and CCA was performed and intraluminal shunt placed (inserted). Perforation site was managed using endoluminal Dacron patch fixating by continuous Prolen suture. Narrow Dacron patch was used for closing arteriotomy. The complete surgical procedure lasted 45 minutes. Immediate and 6-th and 12 month follow up examination were conducted (Duplex scan, carotid artery DSA) evidencing no neurological deficits or any other complications. Preoperative condition, intraoperative findings and postoperative course were clearly and thoroughly documented. The author found endoluminal patch plasty at the site of the rupture-induced defect to be simple and safe method.     

Prevention of left ventricular thrombus formation during pneumatic pump assist

A postcardiotomy patient with a pneumatic pulsatile pump for left ventricular assist showed a smoke-like swirling echo within the left ventricle during pump assist. The image disappeared partially during intra-aortic balloon pumping, which was performed as usual. Subsequently, three pumps (native left ventricle, pneumatic and intra-aortic balloon) were driven synchronously: that is, the ventricular assist pump ejected the blood in the first half of the diastole of the native heart beat, and the intra-aortic balloon was inflated during the second half. With this bisected diastolic driving, the abnormal echo disappeared completely. The patient died 52 days after operation, but no thromboembolic episode was observed during the course, and no fresh thrombus was found within the left ventricle at autopsy. The bisected diastolic driving method served as an aid to prevent stagnation of blood and thrombus formation within the native left ventricle in this patient with a left ventricular assist device.     

Fluoroscopy-assisted dual-catheter thromboembolectomy: a new technique useful in patients with embolization to arteries of disproportionate diameters

Distal embolization is a complication of aortoiliac aneurysm repair. Fluoroscopy-assisted catheter thromboembolectomy is useful in removing popliteal and tibial emboli from the femoral approach. Concomitant presence of aortoiliac and popliteal aneurysms, a known association, may present a difficult challenge to embolus extraction. Currently available embolectomy catheters large enough for thrombus extraction from a popliteal aneurysm are too large for safe tibial artery cannulation, and tibial balloon catheters cannot be enlarged sufficiently to transfer the thrombus through the aneurysmal popliteal segment. We treated a patient who embolized to his popliteal aneurysm and distal tibial circulation following aortoiliac aneurysm repair. A fluoroscopy-assisted dual-catheter technique was used to extract the thrombus through the femoral approach, eliminating the need for direct popliteal or tibial exploration. This technique uses two balloon catheters of graduated size, maneuvered concurrently under fluoroscopic guidance into the tibial and popliteal circulation. The smaller tibial catheter is inflated, and thrombus is withdrawn into the popliteal segment. The larger popliteal balloon catheter is then inflated distal to the smaller catheter, and both catheters are withdrawn simultaneously to deliver the clot through the femoral arteriotomy. This technique can be useful for successful balloon catheter extraction of thrombus via remote access, in an arterial system with variable diameter, eliminating the need for direct popliteal or tibial exploration.     

Simple new method for making a rat carotid artery post-angioplasty stenosis model

A simple new method for making a rat post-angioplasty stenosis model was developed using a single-lumen compliant balloon catheter/guidewire system and no special diet. This technique was applied to 10 9-week-old Wistar rats fed a normal diet. The catheter/guidewire system was inserted from the external carotid artery and advanced retrogradely into the common carotid artery. The balloon was inflated six times with rotation through 60 degrees . After angioplasty, the external carotid artery was ligated. Homogeneous stenoses due to intimal hyperplasia were demonstrated in cross sections of all cases. This simple and gentle method allows an easily reproducible post-angioplasty stenosis model.     

Non-infected carotid artery pseudoaneurysm 29 years after endarterectomy, endovascular management with covered stent

Pseudoaneurysm formation is a rare complication following carotid endarterectomy (CEA). Arterial pseudoaneurysms lack all three layers of the arterial wall that include the intima, media and adventitia. Pseudoaneurysms are most commonly seen after injuries to the artery in the form of blunt trauma and puncture, and are less common after surgeries such as carotid endarterectomy. These lesions present most frequently as enlarging, pulsatile, expandable masses associated with swelling and pain. Management of this complication is challenging. Traditionally, open surgical repair has been the preferred treatment. Recently, endovascular techniques using stent graft implantation alone or combined graft and coil embolization have offered a less invasive approach for the management of this lesion. Pseudoaneurysm development has been described within hours to several years after initial arterial injury, normally presenting within 5 years. To our knowledge, this is the first case report of pseudoaneurysm formation in a patient presenting 29 years after a carotid endarterectomy; during that time the patient remained completely asymptomatic until 2 months prior to his admission. The patient is an 84-year-old male with a history of stroke which prompted a left carotid endarterectomy in 1981. Twenty-nine years post procedure it was noted that the patient had a lump that was progressively enlarging on the left side of his neck, zone 1. It was pulsatile on examination. MRI/A imaging suggested a left carotid bulb aneurysm. The consulting vascular surgeon felt the patient would not be a good surgical candidate and so stenting was considered. Carotid and cerebral angiogram demonstrated a large 6 cm left carotid pseudoaneurysm off the carotid bulb. The diagnostic procedure was followed by a successful placement of an 8 x 10 cm Viabahn covered stent from the left common carotid artery to the left internal carotid artery. Following the procedure, the carotid artery was patent and there was minimal to no further residual filling of the pseudoaneurysm. Poststenting, the patient remained at his neurological baseline. This case demonstrates that pseudoaneurysm formation can occur as a long term complication after carotid endarterectomy. It may present as a rapidly expandable, pulsatile, vascular lesion in the absence of clinical and sub-clinical infection. Placement of an endovascular stent graft may be a safe and effective option for treatment of infected and non-infected carotid pseudoaneurysm.     

Carotid endarterectomy in chronic renal failure patients: report of two cases

Chronic renal failure is one of the risk factors for carotid atherosclerosis. We report two cases of stenosis of the carotid bifurcation treated by carotid endarterectomy. A 66-year-old man with a 17-year history of hemodialysis experienced repeated episodes of right hemiparesis. Cerebral angiography showed severe stenosis of the cervical carotid bifurcation bilaterally. Left and right carotid endarterectomy operations were performed one month apart. The postoperative course was uneventful, and the patient returned home without neurological symptoms. The second case was in a 49-year-old woman with a 15-year history of hemodialysis had vertigo of one month duration. Cerebral angiography revealed occlusion of the left subclavian artery, and the distal left axillary artery was filled by retrograde flow from the left vertebral artery. Stenosis of the right carotid bifurcation was also noted. Right carotid endarterectomy was performed without any complications. Although a high incidence of intraoperative complications and of recurrent stroke after carotid endarterectomy (CEA) has been reported in chronic renal failure patients, the poor prognosis of the natural history of severe carotid stenosis in chronic renal failure should be taken into consideration. The cases reported indicate that carotid endarterectomy is safe and justified for carotid stenosis in chronic renal failure patients.     

Open operative balloon angioplasty of the internal carotid artery: A technique in evolution

Open operative balloon angioplasty is a treatment alternative for certain nonatherosclerotic lesions of the internal carotid artery (ICA) including fibromuscular dysplasia (FMD). Standard operative exposure of the carotid bifurcation is performed with atraumatic passage of a guidewire and balloon through a carotid bulb arteriotomy. Under direct fluoroscopic guidance, precise dilatation of the involved area is possible with minimal risk of intimal tear/flap or distal embolization as compared with graduated intraluminal dilatation or percutaneous balloon angioplasty. Vascular control of the common and external carotid arteries lessens the risk of embolization resulting from the constant backflow of blood through the ICA before, during, and after balloon angioplasty, adding to the overall safety and efficacy of the procedure. We report a case of asymptomatic critical carotid artery stenosis associated with FMD successfully treated with open operative balloon angioplasty and review the current literature regarding treatment options for FMD of the ICA.Presented at the Annual Meeting of the Southern California Chapter of the American College of Surgeons, Newport Beach, Calif, January 23, 1994.