Treatment of hemodynamic insufficiency in chronic CCA occlusion using a short saphenous vein interposition graft: diagnostic and technical considerations

Abstract

Extracranial-intracranial bypass surgery has been shown to reverse hemodynamic insufficiency on the basis of steno-occlusive disease of the internal carotid artery (ICA) or middle cerebral artery. In contrast, chronic occlusion of the common carotid artery (CCA) without extracranial donor vessels affords alternative revascularization procedures as well as a more elaborate preoperative workup. This case is intended to illustrate the specific diagnostic approach and considerations as well as a beneficial treatment modality in the setting of pronounced hemodynamic insufficiency as a consequence of a CCA occlusion, in conjunction with contralateral CCA and ICA stenoses. A 61-year-old man complaining of new onset aphasia underwent vascular imaging that revealed a proximal occlusion of the left CCA with a concomitant patent proximal ICA on ultrasound. Functional cerebral blood flow measurement including Xenon-enhanced computer tomography showed corresponding chronic hemodynamic insufficiency of the left hemisphere. The patient received a modified revascularization procedure, where a saphenous vein was used as interposition graft between the subclavian artery and the left proximal ICA. Postoperatively, both clinical and morphological improvement were noted. Successful treatment of hemodynamic insufficiency because of chronic CCA occlusion necessitates a thorough preoperative workup and application of alternative revascularization strategies.

Common Carotid Artery Occlusion: A Single-Center Experience in 40 Cases

“…Among the 21 published studies on CCAO treatment, 11 were case reports involving a total of 16 patients. [8][9][10][11][12][13][14][15][16][17] The other 10 studies 2,18-25 involved 6 to 24 patients, with a total of 130 patients.…”

Angioplasty and Stenting of Totally Occluded Common Carotid Artery at the Chronic Stage -Case Report-

“…Surgical treatments for occluded CCA are well known, and consist of bypass surgery with a vessel graft 3) or long segment endarterectomy. 2) Compared to these surgical approaches, the endovascular approach seems less invasive.…”

“Isolated Carotid Bifurcation” and Vertebral-Carotid Artery Bypass for Common Carotid Artery Occlusion

“…2,7,8) Vascular reconstruction surgery for CCA occlusion has no established benefit, and generally requires a technique with which many neurosurgeons are unfamiliar. 2,9) Subclavian-carotid artery bypass using a saphenous vein graft (SVG) is the most commonly used procedure in this situation. 12) This procedure can be modified in terms of the selection of donor arteries, type of interposition graft, and requirement for upper thoracic exposure, depending on the lesion involved.…”