External Carotid Artery Stenting and Superficial Temporal Artery to Middle Cerebral Artery Anastomosis for Internal Carotid Artery Occlusion With External Carotid Artery Severe Stenosis

Abstract

Superficial temporal artery (STA) to middle cerebral artery (MCA) anastomosis may have inadequate effects in patients with internal carotid artery (ICA) occlusion and severe stenosis of the ipsilateral external carotid artery (ECA), because poor blood flow in the STA leads to insufficient flow to the MCA. In these patients, dilation of the stenotic ECA is required to improve the blood flow in the STA before STA-MCA anastomosis. A 71-year-old man presented with left hemiparesis and dysarthria. Magnetic resonance imaging revealed an old watershed infarction in the right cerebral hemisphere. Right carotid angiography showed right ICA occlusion and severe ipsilateral ECA stenosis. Single photon emission computed tomography (SPECT) demonstrated severe hemodynamic insufficiency in the right MCA territory. Instead of endarterectomy of the ECA, angioplasty and stenting (CAS) for ECA was performed to ensure adequate blood flow in the STA, due to the history of myocardial infarction and bifurcation of the common carotid artery at a high level (C2 level). Then STA-MCA anastomosis was performed 1 month later. Postoperative SPECT demonstrated marked improvement of hemodynamic insufficiency in the right MCA territory. After treatment, the patient had no ischemic events. This case suggests external CAS together with STA-MCA anastomosis is a good therapeutic option for a patient with symptomatic ICA occlusion and severe stenosis of the ipsilateral ECA if external CEA is difficult to perform.

Staged Common and External Carotid Artery Stenting Followed by Superficial Temporal Artery to Middle Cerebral Artery Bypass

“…Clearly, the benefit of EC-IC bypass surgery will be inadequate in the setting of ECA stenosis. 10,18 Vein bypass from the left subclavian to the ECA, followed by STA-MCA bypass has been reported in a patient with left CCA and ICA occlusion. 19,20 ECA endarterectomy followed by STA-MCA bypass has been performed for symptomatic patients with ICA occlusion and severe ECA stenosis, though not with concomitant CCA occlusion.…”

“…Surgery is therefore precluded in patients with CVSOD affecting the external carotid system. There are several case reports of blood flow augmenting procedures for STA-MCA bypass in patients with ECA stenosis [10][11][12] however there are no reports of recanalisation of an occluded common and external carotid system prior to STA-MCA bypass.…”

Vascular Reconstruction for Radiation-induced Bilateral Internal Carotid Artery Occlusion and Unilateral External Carotid Artery Stenosis by a Combination of Surgical and Endovascular Method: Case Report

“…This strategy was essentially the same as done by Oku et al in a patient with atherosclerotic ICA occlusion and ipsilateral ECA severe stenosis. 16) It was rather simple and safe by methods used in usual clinical practice. They performed CAS for ECA severe stenosis before STA-MCA anastomosis because the stenotic lesion of the ECA was high (C2 level) for carotid endarterectomy (CEA).…”

External carotid stenting for symptomatic stenosis in a patient with patent EDAS for Moyamoya disease

“…These reports support either ECA stenting or endarterectomy in the face of concurrent ICA occlusion as a viable means of managing ipsilateral ICA occlusion. The reports by Ko et al ,8 Kawamata et al ,7 and Oku et al 11 are particularly relevant as they reference patients who received ECA intervention as a preventative before undergoing STA–MCA bypass. While our patient had different circumstances, the similarity in pathophysiological presentation and successful treatment of these patients supported our therapeutic decision-making.…”