Internal Carotid Aneurysm Resection With Primary Repair Using Active Flow Reversal For Neuroprotection
Louis Graham Rucker, MD, Evan Neville, MD, Brent Robertson, MD, Brian A. Kuhn, MD, Mark Broering, MD, Aaron Kulwicki, MD, Patrick Muck, MD, Matthew Recht, MD.
TriHealth, Cincinnati, OH, USA.
DEMOGRAPHICS A 63-year-old male presented with left arm and leg weakness. HISTORY MRI confirmed a stroke in the right middle cerebral artery distribution in the setting of a large saccular, distal extracranial internal carotid artery aneurysm at the C2 level. It was felt the best option to prevent subsequent embolic stroke would be to perform an open repair to resect the aneurysm with the use of active flow reversal for neuroprotection prior to manipulation of the aneurysm.
PLAN Under general anesthetic a cutdown on the right common carotid artery was performed through a transverse supraclavicular incision. The ENROUTE (Silk Road Medical, Sunnyvale, Calif) neuroprotection system was inserted and connected to the femoral vein return sheath. The common carotid artery was clamped proximal to the arterial sheath and flow reversal was initiated. A separate longitudinal incision was used to dissect out the carotid bifurcation and internal carotid artery. A large saccular aneurysm was identified at the distal internal carotid artery (ICA). The ICA was clamped distal and proximal to the aneurysm. With distal control, flow reversal was stopped. A shunt was then placed and the aneurysm was resected to normal artery proximal and distal and repaired in an end-end fashion. DISCUSSION Extracranial carotid artery aneurysms may lead to neurologic symptoms including transient ischemic attacks or ischemic stroke. Currently, there is no consensus on the optimal management of this disease and treatment varies widely.Advances in endovascular surgery have led to new approaches in the treatment of extracranial internal carotid artery aneurysms. Trans carotid artery revascularization was initially developed as an alternative to transfemoral carotid artery stenting and carotid endarterectomy for atherosclerotic disease with reversal of flow for cerebral protection in high surgical risk patients The neuroprotection principles of TCAR were adopted for cerebral protection from embolic disease during dissection of the aneurysm. The extracranial carotid artery aneurysm was successfully repaired with active flow reversal for neuroprotection prior to manipulation of the internal carotid artery and aneurysm. The patient remains free from further neurological events Active flow reversal can provide excellent neuroprotection during difficult open operative anatomy in symptomatic ICA aneurysms.
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