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Auxiliary Use Of Flow Reversal System In A Patient With Substantial Risk Of Distal Thromboembolism During Carotid Endarterectomy
Saroj Kumar Yadav, MD, Abdul Waheed, MD, Subhasis Misra, MD, FACS, Dariam C. Oliva, MD.
Baycare Health System, St. Joseph Hospital, Tampa, FL, USA.
Background: Traditional surgical techniques to reduce this risk have demonstrated varied outcomes. This case report describes using a flow reversal system as an adjunctive technique to prevent distal embolization in a patient with a high risk of thromboembolism undergoing carotid endarterectomy.
Methods: A 52-YOF presented with left upper extremity weakness and transient visual disturbances. Her medical history included diabetes, hypertension, and hypothyroidism. On exam, patient had persistent neurologic deficits with left upper extremity weakness. CTA head and neck revealed a right ulcerated plaque at the carotid bulb with 1.5cm of free-floating thrombus extending into the Internal Carotid Artery (ICA). MRI demonstrated multiple acute right hemispheric strokes. Patient was initially managed with anticoagulation, with repeat imaging at 48h. Despite adequate anticoagulation with heparin drip, the thrombus persisted on repeat imaging, and patient was taken to the operating room for a right carotid thromboendarterectomy.
Results: First, the proximal common carotid artery (CCA) was exposed through a small longitudinal incision between the heads of the sternocleidomastoid (SCM) muscle over the clavicle. Flow reversal was instituted using the Enroute Neuro Protection System (NPS) after heparinization. The incision was then extended cephalad along the medial edge of the SCM for standard carotid endarterectomy exposure using the no-touch technique. The common and external carotid arteries were clamped. Longitudinal arteriotomy was performed over the CCA and extended into the ICA, allowing for ICA back bleeding. The ICA thrombus was not present but with adequate back bleeding from the ICA, it was clamped. Reversal of flow proximal to the CCA clamp was discontinued and the Enroute NPS filter examined which contained a substantial clot burden, consistent with the known ICA thrombus. The rest of the endarterectomy proceeded standardly with a bovine pericardial patch. Completion cerebral angiogram demonstrated no evidence of distal embolization, and the patient had no new neurological deficits upon emergence from anesthesia. She was discharged home on postoperative day 2 on dual anti platelet therapy. Follow up in clinic 2 weeks later demonstrated near complete resolution.
Conclusion: Using flow reversal system as an adjunct during carotid endarterectomy appears effective in reducing the risk of distal thromboembolism in patients with floating thrombi. However, further research is needed to fully assess the long-term effectiveness and potential limitations of this approach.
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