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.
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Mika Niemelä, Reza Dashti, Juha Hernesniemi, Helsinki, Finland
One should be innovative in thinking like the authors and not be satisfied with ‘routine’ bypass methods when there still would be a need for one. After the EC/IC bypass study, there were only a few centers in the world that continued with bypass surgery. Now, there is a growing demand for bypasses, and the number of centers performing them is increasing. This study also addresses nicely the importance of dedicated neurovascular centers with multidisciplinary teams in taking care of the more and more demanding cases left for open microneurosurgery. This encourages young vascular neurosurgeons first to go to the lab to learn the techniques, then to travel to see the masters before starting their own practice.
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David J. Langer, New York, USA
The authors nicely illustrate a creatve surgical management strategy in a patient presenting with common carotid occlusion manifesting clinical evidence of hemispheric hypoperfusion. The patient was found to maintain a patent ICA distal to the occlusion filling from the extra- and intracranial collaterals. The selection of an entirely extracranial revascularization strategy permitted flow augmentation to be established without exposing the patient to the risk of general anesthesia and craniotomy. This novel approach resulted in apparently excellent clinical outcome and reflects the importance of a comprehensive radiographic workup, which includes four-vessel angiography and hemispheric perfusion studies before consideration of surgery can be made. The authors utilize XeCT to determine hemispheric blood flow and CVRC. We additionally use VasSol MR imaging Noninvasive Optimal Vessel Analysis (NOVA) to noninvasively quantify volumetric blood flow rate in individual vessels. NOVA gives information regarding individual quantitative vessel blood flow and direction, allowing greater sophistication in understanding cerebral blood flow preoperatively.
The authors should be commended for designing an operative strategy that allowed a high likelihood of revascularization with the lowest possible perioperative risk.
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Schubert, G.A., Rewerk, S., Riester, T. et al. Treatment of hemodynamic insufficiency in chronic CCA occlusion using a short saphenous vein interposition graft: diagnostic and technical considerations. Neurosurg Rev 31, 123–126 (2008). https://doi.org/10.1007/s10143-007-0104-6
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DOI: https://doi.org/10.1007/s10143-007-0104-6