You are due to operate on a 70 year old lady who had an episode of TIA 10 days ago. She has two Doppler scans the last of which is 7 days old showing a very tight left ICA stenosis > 90 %. She has a short neck and limited neck extension.
Discuss your preoperative and operative approach principles.
In the same case you identify that she has a low bifurcations and a tortuous elongated ICA.
What are the common pitfalls and how to avoid them?
1 order another duplex
2 pit fall it could be kinked after removal of plaque so I might consider resection anastomosis
Discuss your preoperative and operative approach principles.
preoperative
Routine investigations which include full lab Echo and chest X-ray if indicated.
I will ask for CTA to give better imaging and planning
I will explain all the possible complications to the patient for consent
I will go for classic endarterectomy or eversion technique
In the same case you identify that she has a low bifurcations and a tortuous elongated ICA.
What are the common pitfalls and how to avoid them?
it could cause ICA stenosis and thrombosis which could be avoided by exciscion of part of the ICA or Eversion technique
for this challenging case,
I will request CTA to confirm these data. preoperatively I will mark the bifurcation US guided before skin incision.
I will counsel the patient with all possible options and complications
I may discuss the option of carotid stenting.
I will discuss with maxillofacial surgeon to perform temporomandibular subluxation
I will ask the anesthetist to do nasopharyngeal tube to allow full neck extension
during surgery, I may need to divide some of ECA branches and/or post belly of digastric.
if the ICA is tortuous, the eversion technique will be better as it avoids kinking or stenosis
1 order another duplex
2 pit fall it could be kinked after removal of plaque so I might consider resection anastomosis
This case is challenging for both open surgery and CAS,
Challenges to open surgery are the short neck and the limited neck extension which would affect exposure.
I don’t think that low bifurcation is a problem.
The other issue is ICA tortuousity which would hinder CAS procedure.
Q1. Preoperative assessement of cervical x ray or MRI and discuss to use Head fram fixation and extension intraoperative with nasotracheal intubation and if there is difficulty during planning CTA and CAS is other choise
Q2.
Low bifurcation difficult proximal exposure & control of CA we can avoid that by used CAS but extensive tourtosity of ICA is contraindication for stenting if possible to get proximal control and do eversion endartectomy it will be satsfied procedure
Thank you for your excellent response.
what finding are you looking for in the XR or MRI and how will you act on them ?
What is the role of Headframe in such cases?
Any other steps other than transnasal intubation.
Low bifurcation is usually accessible and if needed the omohyoid muscle can be divided
what are your concerns with low bifurcations ?
Q1. Fused cervical vertebrae or cervical spondyosis also we can determine the level of bifurcation related to cervical vertebra
Q2 help in more fixation, extension and rotation of neck.
Q3. Extended skin incision, anterior sublaxation of mandible, retraction or division of posterior belly of diagastric muscle, mandibular ostetomy, and secure taping of mandible
Q4. Increase rsk of Injury to recurrent laryngeal nerve and thoracic strictures