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14-JUNE-2006 JALLAL YOUSEF SALEH AL-TCI
64 YEARS COMPLETE OCCLUSION OF THE LEFT ICA AFTER STENTING PART
- 2
The patient under G.A with nasal intubation, in case he needs high
dissection, were performed. Incision was made to expose the distal 3
cm of the CCA and the ICA until the upper edge of the stint was
felt. The ECA was dissected and the superior thyroid artery. All was
done with the BP of the patient kept at 170/100 mm Hg. and
continuous cover of the patient with 500 units of heparin/hour.
An-Argyle-like tube was prepared in case, but when it was found
that, the back flow of the ICA was weak, it was decided that, no
need for such shunting. For technical details of the operative
details, you can refer to
this article.
The atheroma was
completely occluding the soft construct of the stint, with minimal
clot inside the very shallow space inside the compressed stint.
After removal of the stint, it regained its cylindrical
configuration, as seen in the lower pictures.
Water-tight closure of the vascular wall with 6 zero nylon and
the carotid bulb and major branches were checked for the flow and
presence of bleeding points. Meticulous heamostasis and ready-vac
drain No 8 left in the wound.
Prompt postoperative recovery, and the patient immediately showed
mild recovery in his speech and the power of his right hand. CT-scan
of the brain was performed immediately after surgery to rule out
progression of heamatoma. The patient kept in the ICU for heparin
infusion 650 units/hour and for strict observation of his vital
signs.
Comments:
Stinting is
a good thing, but it is still needs many corrections in the
technology. As we know the carotid bulb wall has a strong wall
capable of constricting the stint with furthermore atheroma
formation inside the shallow compressed stint as in the sample
before me, which I removed it.
To resolve this problem, my advice is to make the stint from 2 parts
intermingled with each other. The first is what is in the production
now and the second part to be interweaved in the first half of the
construct to offer 2 advantages. The holes will be less wide,
eliminating the progression of the atheroma inside the stint, second
to aid the strength of the construct, to maintain the patency of the
lumen. It seems from the case shown, that the complete occlusion was
the result of these 2 factors.
The stent with the surrounding atheroma, which were completely
occluding all the major branches. The atheroma shrunk, because the
photos were performed 15 hours after exposure to the air.
Stages of atheroma with stint removal. Notice that the atheroma was
extending far to the ECA and even the STA!
Check MRA performed 16-July-2006 showing the patency and established
circulation 1 month after the operation.
