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Complex Carotid Endarterectomy With Stent Explant For Recurrent Carotid Stenosis After Tcar
Sabrina Straus, Mahmoud Malas.
UCSD, La Jolla, CA, USA.
DEMOGRAPHICS 70-year-old male with a history of hypertension, hyperlipidemia, hypothyroidism, and left vertebral steal syndrome secondary to left subclavian artery stenosis presented with recurrent left carotid artery stenosis.
HISTORY The patient initially had left-sided TCAR for symptomatic high-grade carotid stenosis, which was followed by recurrent stenosis a year later, requiring drug-coated balloon angioplasty. One year following this intervention, the patient developed severe restenosis within the stented segment.
PLAN Given the complexity and recurrence of stenosis, a decision was made to explant the stent. The patient was counseled regarding increased risks of bleeding, infection, cranial nerve injury, stroke, myocardial infarction, and mortality, and provided consent to proceed with the procedure. A segment of the right GSV was harvested prior to neck dissection. Careful anterior cervical dissection was then performed to expose the left carotid artery. The hypoglossal nerve was identified and mobilized by ligating a distal branch of the external carotid artery. The dissection was extended superiorly, necessitating the division of the posterior belly of the digastric muscle to gain adequate exposure and protect the distal ICA near the skull (Figure 1A). The ICA was clamped proximally and distally. An eversion arteriotomy was then performed with a #15 blade along the anterior aspect of the common-to-internal carotid artery, avoiding the stent (Figure 1B), to facilitate en bloc removal of the plaque and stent (Figure 1C). With the posterior arterial wall preserved, a bypass procedure was avoided, and a saphenous vein graft was used for patch angioplasty at the distal ICA (Figure 1D). Following repair, intraoperative Doppler ultrasound demonstrated excellent flow through the ICA and confirmed there was no residual flap for dissection. Hemostasis was achieved, a drain was placed, and the wound was closed in layers. The patient had an uneventful postoperative recovery, remained neurologically intact, and was discharged on postoperative day one.
DISCUSSION Recurrent carotid stenosis after TCAR or tfCAS is challenging; however, this case report highlights the importance of surgical flexibility, demonstrates the feasibility of safe stent explantation, and provides effective techniques for distal ICA exposure, en bloc stent and plaque removal, and posterior wall preservation.
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