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Most of the site will reflect the ongoing surgical activity of Prof. Munir Elias MD., PhD. with brief slides and weekly activity. For reference to the academic and theoretical part, you are welcome to visit  neurosurgery.fr

 
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 hematoma. 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 atheroma with the stent from behind  The same from anterior after bisecting the atheroma.
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.

Exposure of the atheroma in the CCA. Sharp cut of the atheroma at the CCA.
The lower edge of the stent is seen inside the atheroma. The stent and atheroma completely occluding the ICA.
Fine dissection is going on. The atheroma is removed from the superior thyroid artery.
The atheroma is dissected from th ECA. Cutting the atheroma from the ECA.
Further cleaning of the debris after removal of the mess. The carotid bifurcation after repair with nylon 6 zero.
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.

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[2006] [CNS CLINIC - NEUROSURGERY - JORDAN]. All rights reserved