Scientific and epidemiologic progress surrounding carotid artery surgery continues to evolve, and for the better, for both surgeons and patients. Carotid surgery, performed by skilled surgeons with quantifiable results, prevents stroke in asymptomatic and symptomatic patients. The challenge is to continually refine the techniques to ensure the greatest possible margins of safety, and to educate surgeons around the world to ensure uniform standards of care. Carotid artery stenting, again performed by skilled practitioners with quantifiable results, has developed as a viable alternative to CEA in chosen cases.
Carotid Treatment, Third Edition represents the current state of the art in carotid treatment. Coverage includes a comprehensive and practical new chapter on carotid stenting, increased coverage of radiography, and highly illustrated surgical technique case examples reflecting international practice. Throughout the book numerous case examples, and interesting examples of anatomical variants are illustrated and explained. An expanded section on complications further increases the value of this resource for all practitioners.
Highly illustrated text to aid understanding of best practice in carotid treatment
Reflects international best practice
Useful in clinical practice and to improve patient care
Neurosurgeons, Vascular surgeons, and Neuro-Interventionalists will benefit from the experience and wisdom shared in the third edition of this acclaimed text.
Author(s): Christopher Miranda Loftus, Satoshi Kuroda, Naoya Kuwayama
Edition: 3
Publisher: CRC Press
Year: 2022
Language: English
Pages: 440
City: Boca Raton
Cover
Half Title
Title Page
Copyright Page
Dedication
Contents
Preface to the Third Edition
CHAPTER 1: Foundation and Evidence for Carotid Reconstruction
History
Scientific Foundation for Carotid Artery Treatments
Best Medical Therapy (Asymptomatic or Symptomatic)
Asymptomatic Carotid Disease
Asymptomatic Bruit
Contralateral Carotid Stenosis
Carotid Risks in Non-Carotid Pre-Operative Patients
Hollenhorst Plaque
Symptomatic Carotid Disease
Transient Ischemic Attacks
Acute Neurological Deficit
Subacute Complete Carotid Occlusion
Stump Syndromes
Special Considerations with Recent Stroke
Clinical Evaluation
Special Surgical Considerations
Plaque Ulceration and Stroke Risk Markers
Critical Stenosis
Intra-Luminal Thrombus (ILT)
Contralateral Carotid Occlusion
Tandem Lesions of the Carotid Siphon
Concurrent Carotid Disease and Intra-Cranial Aneurysm
Recurrent Carotid Stenosis
Concurrent Coronary/Carotid Disease
Technical Considerations
Anesthesia Choice
Local/Regional Anesthesia
General Anesthesia
Monitoring Techniques during Carotid Cross-Clamping
Monitoring Techniques under GA
Intra-Operative Shunting
Is the Shunt Needed?
Insertion of the Shunt
Is the Shunt Working?
Arteriotomy Techniques
Patch Grafting
Tacking Sutures
Heparinization
Surgical Technique of Cervical Carotid Reconstruction
Indications
Pre-Operative Studies and Preparation
Surgical Technique
Special Considerations
Micro-Surgical Endarterectomy
Bilateral Carotid Endarterectomy
Complete Occlusion
Acute Stroke
Post-Operative Considerations
Complications of Carotid Revascularization
Rationale
Complications Following Surgery
Endovascular Treatment of Carotid Stenosis
Best Outcomes with CEA
Best Outcomes with CAS
“High-Risk” Patients
References
CHAPTER 2: Historical Perspective and Current Practice of Carotid Artery Stenting (CAS)
Historical Review and Recent Evidence
(1) Less Favorable Studies for CAS
(2) More Favorable Studies for CAS
(3) Meta-Analysis
(4) Comparative Study with Medical Treatments
Techniques for Carotid Artery Stenting
Techniques to Address Peri-Procedural Risk Management in CAS
(1) Antiplatelet Therapy (Thromboembolic Risk)
(2) 3D-CTA for Evaluation of Access Routes (Anatomical Risk)
(3) Assessment of Cardiac Function (Cardiac Risk)
(4) Plaque Images (Plaque Risk)
(5) Evaluation of Cerebral Blood Flow (CBF) Risk
Technical Considerations during the CAS Procedure
(1) Monitoring
(2) Approach Routes
(3) Embolic Protection Methods
(4) Stent Selection
(5) Standard Procedure of CAS
Summary of Settings and Monitoring
Procedures
Post-Operative Monitoring
Follow-Up of the Patients
(6) Special Considerations
Two-Staged Angioplasty for Patients with High Risk for Post-Procedural Hyperperfusion Syndrome
Complications of CAS
References
CHAPTER 3: Radiographic Studies
3-1. Low Bifurcation of the Carotid Artery with Symptomatic Plaque Just at the Origin of the Internal Carotid Artery
3-2. High Bifurcation of the Cervical Carotid Artery
3-3. Side-by-Side
3-4. Focal Internal Carotid Artery Ulcer
3-5. Deep Ulceration of a Carotid Plaque
3-6. Benign Arteriogram—Bad Ulceration
3-7. Ninety-Five Percent Lesion
3-8. Extensive Plaque in Common Carotid Artery with Long Arteriotomy
3-9. String Sign
3-10. X-Ray Identification of an Ascending Pharyngeal Artery Originating at the Carotid Bifurcation
3-11. Tandem Stenosis
3-12. Cross Filling into Contralateral Middle Cerebral Artery
3-13. Can We Predict the Need for Shunting?
3-14. Pre-Operative External Carotid Artery Occlusion
3-15. Internal Carotid Stump
3-16. Carotid Kink
3-17. Carotid Stenosis with Distal Cervical Aneurysm
3-18. Intra-Luminal Thrombus
3-19. Complication—Clot along Suture Line
3-20. Complication—Complete Post-Operative Occlusion
3-21. Complication—External Carotid Artery Dissection
3-22. Morphology and Plaque Content
Carotid Ultrasound
Plaque MRI
18F-Fluorodeoxyglucose (FDG) PET
Cerebral Hemodynamics
15O Positron Emission Tomography (PET)
Single Photon Emission Tomography (SPECT)
Hyperperfusion Syndrome after CEA/CAS
Non-Invasive Mra and Cta for Surgical Planning
References
CHAPTER 4A: Surgical Technique – Christopher Loftus
4-1. Surgical Instruments
4-2. Surgical Positioning
4-3. Alternate Incisions
4-4. Side-by-Side Positioning
4-5. Incision for High Bifurcation
4-6. Ease of Dissection and Exposure
4-7. Draped and Ready for Incision
4-8. Platysma with Michel Clips
4-9. External Jugular Vein
4-10. Sternocleidomastoid Muscle
4-11. Jugular Vein—Common Facial Vein
4-12. Ligation of the Common Facial Vein
4-13. Secure Ligation of the Common Facial Vein
4-14. Minor Branches of Facial Vein
4-15. Dissection behind the Parotid Gland
4-16. First Demonstration of Common Carotid Artery with Control
4-17. First CCA Control with 0 Silk Tie and Rummel Tourniquet
4-18. Exposure of Carotid Artery with Retractors
4-19. Ring Clamp and Blunt Fish-Hook Retraction for Total Carotid Exposure
4-20. Four Sutures in the Carotid Sheath
4-21. Unexpected Internal Carotid Artery Atresia
4-22. Thyroid Mass Found at Time of CEA—Right-Sided Exposure
4-23. Major Nerve Structures Potentially Injured during Carotid Endarterectomy
4-24. Other Nerves at Risk during Carotid Endarterectomy
4-25. Low Bifurcation with Omohyoid Muscle
4-26. Isolation of Omohyoid
4-27. Retracted Omohyoid
4-28. Division of Omohyoid Muscle to Secure Adequate Low Carotid Exposure
4-29. Hypoglossal Nerve
4-30. Sternomastoid Artery—An External Carotid Artery Branch
4-31. High Bifurcation with Digastric Muscle and Hypoglossal Nerve—Left Carotid Exposure
4-32. High Bifurcation with Digastric Muscle and Hypoglossal Nerve—Right Carotid Exposure
4-33. Side-by-Side Carotid Anatomy—Exposure
4-34. Isolation of Superior Thyroid Artery—Right Carotid Exposure
4-35. Isolation of Superior Thyroid Artery—Left Carotid Exposure
4-36. Isolation of Ascending Pharyngeal Artery (Left)
4-37. Isolation of Ascending Pharyngeal Artery (Right)
4-38. Clues to the End of the ICA Plaque
4-39. Tactile and Visual End of Plaque—Left Carotid Exposure
4-40. Tactile and Visual End of Plaque—Right Carotid Exposure
4-41. Doppler Auscultation for Extent of Plaque
4-42. Extensive Plaque Erosion into the Adventitial Layer
4-43. Javid Clamp around Internal Carotid Artery
4-44. Loftus Shunt Clamps
4-45. Placement of Cross-Clamp below Rummel Tourniquet
4-46. Incision along Common and Internal Carotid Arteries (Blue Line)—Left Carotid Exposure
4-47. Potts Scissors Opening—Left Carotid Exposure
4-48. Potts Scissors Opening Vessel—Left Carotid Exposure
4-49. False Plane Demonstrated with Penfield Retractor—Right Carotid Exposure
4-50. Focal Plaque in Proximal Internal Carotid Artery—Left Carotid Exposure
4-51. Long, Extensive Common Carotid Artery/Internal Carotid Artery Plaque
4-52. Shunt in Common Carotid Artery/Internal Carotid Artery
4-53. Initial Placement of Shunt Down Common Carotid Artery
4-54. Securing of Shunt in Common Carotid Artery
4-55. Bleeding and Evacuation of Shunt before Placement in Internal Carotid Artery
4-56. Placement of Shunt in Distal Internal Carotid Artery
4-57. Potential for Intimal Damage from Placement of Shunt
4-58. Securing of Shunt in Internal Carotid Artery
4-59. Loftus-Type Carotid Shunt in Place—Two Views
4-60. Evaluation of Shunt Function
4-61. Repair with Shunt in Place
4-62. Plaque Removal Begins at Lateral Edge—Left Carotid Exposure
4-63. Sharp Transection in Common Carotid Artery—Right Carotid Exposure
4-64. Sharp Scissors Transection of CCA Plaque
4-65. Plaque Removal from Internal Carotid Artery (Feathered Edge)—Right Carotid Exposure
4-66. Plaque Removal from External Carotid Artery—Left Carotid Exposure
4-67. Opening of External Carotid Artery—Part 1: Inadequate Feathering
4-68. Opening of External Carotid Artery—Part 2: Inadequate Feathering
4-69. Opening of External Carotid Artery Because of Poor Doppler Signal
4-70. Opening of External Carotid Artery—Repair
4-71. Completed External Carotid Artery Repair in a Case with Internal Carotid Artery Hemashield Patch
4-72. Removal of Fragments in Circumferential Fashion—Right Carotid Exposure
4-73. Left Carotid Endarterectomy—Completed Removal, Sharp Margins
4-74. Completed Removal, Sharp Margins—Left Carotid Exposure
4-75. Placement of Tacking Sutures in Internal Carotid Artery
4-76. ICA Single Posterior Tacking Suture
4-77. Clean Edges at Both CCA and ICA—Ready for Repair
4-78. Anatomic Variant—Atherosclerotic Web on Posterior Wall of Vessel
4-79. Repair Beginning in Internal Carotid Artery: Left Carotid Exposure—No Patch Graft
4-80. “No Touch” Technique for the Prolene Suture
4-81. Microscopic Internal Carotid Artery Repair
4-82. Repair Beginning in External Carotid Artery: Right Carotid Exposure—No Patch Graft
4-83. Repair of External Carotid Artery: Left Carotid Exposure—No Patch Graft
4-84. Second Limb of Repair Coming Up Common Carotid Artery—No Patch Graft
4-85. Suture Sequence and Placement of the Hemashield Roof Patch Graft on the Internal Carotid Artery
4-86. Removal of Shunt
4-87. Tying Together—Evacuation of Air: Right Carotid Exposure
4-88. Blunt Needle to Evacuate Air and Debris as Final Step—Patch Graft
4-89. Four Rip-Stop Free Sutures in the Patch Repair
4-90. Sequence of Clamp Removal at Completion of Arteriotomy
4-91. Doppler Examination of Repair: Left Carotid Exposure
4-92. Completed Dry Repair without and with Hemashield Patch Graft
4-93. Y-Shaped Suture Line—No Patch Graft
4-94. FloSeal for Hemostasis in the Carotid Bed
4-95. Surgicel on Dry Repair
4-96. Closure of Sheath
4-97. Closure of Platysma
4-98. Skin and Hemovac
4-99. Skin Closure
4-100. Placement of Saphenous Vein Patch Graft
CHAPTER 4B: Surgical Technique – Satoshi Kuroda
4-101. General Anesthesia and Skin Incision
4-102. Platysma Incision
4-103. Sternocleidomastoid Muscle and Great Auricular Nerve
4-104. Carotid Sheath and Internal Jugular Vein
4-105. Opening of Carotid Sheath
4-106. Common Facial Vein
4-107. Hypoglossal Nerve
4-108. Part 1: Dissection of Common Carotid Artery from Carotid Sheath
4-109. Part 2: Dissection of Common Carotid Artery from Carotid Sheath
4-110. Carotid Sinus Nerve Blockade
4-111. Carotid Clamping
4-112. Incision along Common and Internal Carotid Arteries
4-113. Insertion of Shunt Tube into Internal Carotid Artery
4-114. Insertion of Shunt Tube into Common Carotid Artery
4-115. Observation of Plaque Content
4-116. Start of Endarterectomy
4-117. Endarterectomy on the Opposite Side
4-118. Sharp Transection in Common Carotid Artery
4-119. Sharp Transection in Internal Carotid Artery
4-120. Sharp Transection in External Carotid Artery
4-121. Placement of Tacking Suture in Internal Carotid Artery
4-122. Primary Closure in Internal Carotid Artery
4-123. Primary Closure in Common Carotid Artery
4-124. Removal of Internal Shunt Tube
4-125. Final View of Operative Field
CHAPTER 5: Complications
5-1. Stab Wound of Posterior Carotid Wall
5-2. Acute Post-Operative Internal Carotid Artery Thrombosis
5-3. Technique for Exploration of Complete Carotid Occlusion
5-4. Use of Fogarty Catheters to Re-Open Thrombosed Internal Carotid Artery
5-5. Post-Operative Wound Hematoma
5-6. Aneurysm Formation 4 Years Post-Operatively
5-7. Post-CEA Hyperperfusion Syndrome
5-8. Post-CEA Occlusion of External Carotid Artery
5-9. Post-CEA/CAS DWI-Positive Lesions
5-10. Femoral Artery Pseudo-Aneurysm after Catheter Insertion
References
CHAPTER 6: Special Cases
6-1. Treatment of Isolated Common Carotid Artery Stenosis
6-2. Treatment of “Stump” in an Occluded Internal Carotid Artery
6-3. Repair and Straightening of a Large Left Carotid Kink
6-4. Rapid Recurrence of Stenosis from Myointimal Hyperplasia
6-5. Scarring in the Carotid Sheath in a Case of Recurrent Stenosis
6-6. Re-Operation in a Case Previously Repaired with a Saphenous Vein Roof Patch
6-7. Mild Carotid Stenosis with Repeated Stroke
6-8. Invasion of Inflamed Plaque into the Media and Adventitia
6-9. Cervical Carotid Aneurysm Associated with Marfan Syndrome
Reference
Index
