Society For Clinical Vascular Surgery

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Early carotid revascularization in bilateral carotid occlusions in the setting of major head and neck reconstruction with recent stroke: a case report
Wanda Lam, MD, Robert Hacker, MD.
Metrohealth Medical Center, Cleveland, OH, USA.

OBJECTIVES: Current guidelines for carotid endarterectomy (CEA) or carotid artery stent (CAS) are well established. No criteria exist for the treatment of bilateral carotid occlusions in the setting of patients who need major head and neck reconstruction with recent stroke. Our case demonstrates the safety and benefit of early carotid revascularization in this specific patient population.
METHODS: This case study presents the immediate and short-term outcomes of ipsilateral carotid revascularization in a patient with bilateral carotid occlusions following a history of head and neck radiation and surgical reconstruction complicated by an ischemic stroke. A 61-year-old male diagnosed with recurrent pharyngeal cancer and a history of ipsilateral head and neck radiation underwent pharyngectomy and free flap reconstruction using the facial artery. No preoperative carotid work up was performed. His immediate postoperative course was complicated by POD 1 a flap failure and a right basal ganglia infarct with left sided hemiparesis . Post operatively carotid duplex demonstrated a left chronic carotid occlusion and right mix-aged occlusion with mobile thrombus. With a multidisciplinary approach, the patient underwent a right-sided thrombectomy and primarily repaired carotid endarterectomy by the vascular team and a rotational flap by ENT.
RESULTS: Postoperatively, no additional neurological insults were identified and the patient had a complete neurological recovery including his hemiparesis by POD 6. Also, his head and neck reconstruction demonstrated significant improvement and healing.
CONCLUSIONS: Routine preoperative evaluation of the carotid arteries after a history of neck radiation but prior to additional surgery may prevent flap failure and identify carotid stenosis. Revascularization of the carotid artery in the certain settings may be performed safely with good results.

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