Transverse Cervical Artery Bypass Pedicle for Treatment of Common Carotid Artery Occlusion: New Adjunct for Revascularization of the Internal Carotid Artery Domain

Abstract While revascularization of the acutely or chronically occluded internal carotid artery has become commonplace with modern endovascular techniques, revascularization of an acutely occluded common carotid artery (CCA) is a controversial procedure with unique challenges. These challenges can be related to the lack of observable markers for identifying vessels during navigation or for identifying the exact location and extent of occlusion within the CCA, in addition to wide-ranging treatment risks. In this video, we illustrate the controversial revascularization of a 68-yr-old woman with an acute CCA occlusion who presented with fluctuating neurological symptoms. We believed treatment to be indicated by the lack of adequate collaterals on the intracranial CTA, and fluctuating symptoms in the absence of an intracranial major vessel occlusion, suggesting that the CCA occlusion was exerting important hemodynamic effects and at risk of causing a major stroke without revascularization, despite a low initial NIH stroke score. Though acute recanalization of patients with low NIH stroke score with stent-angioplasty is a controversial procedure, we believed it to be necessary in the case of our patient and believe it will likely be the focus of the next wave of large clinical trials dedicated to acute stroke.

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Extracranial Posterior Communicating Artery Bypass for Revascularization of Patients With Common Carotid Artery Occlusion

Neurosurgery ◽

10.1227/neu.0b013e3181fa325b ◽

2010 ◽

Vol 67 (6) ◽

pp. 1783-1789 ◽

Cited By ~ 7

Author(s):

Ulf Christoph Schneider ◽

Paul von Weitzel-Mudersbach ◽

Karl-Titus Hoffmann ◽

Peter Vajkoczy

Keyword(s):

Carotid Artery ◽

Vertebral Artery ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Common Carotid Artery ◽

Artery Bypass ◽

Artery Occlusion ◽

Carotid Artery Occlusion ◽

Posterior Communicating Artery ◽

Common Carotid Artery Occlusion

Abstract BACKGROUND: Extracranial-intracranial bypass surgery provides blood flow augmentation in patients suffering from intracranial or long-distance conductance artery stenosis or occlusion that otherwise cannot be treated. The standard procedure for these cases is an anastomosis between the superficial temporal and middle cerebral arteries. However, in patients presenting with common carotid artery occlusion, the superficial temporal artery is no longer sufficiently perfused. For these patients, alternative revascularization strategies have to be applied. OBJECTIVE: To describe a novel strategy for revascularization of patients with common carotid artery occlusion, ie, the extracranial posterior communicating artery bypass. METHODS: Two patients with chronic cerebrovascular compromise resulting in transitory ischemic attacks and/or border-zone infarctions caused by common carotid artery occlusion were referred to our institution. A radial artery bypass was established between the third segment of the vertebral artery and an M3 branch of the middle cerebral artery. The vertebral artery was exposed between the vertebral lamina of C1 and occipital bone via a paramedian incision. The bypass was tunneled subcutaneously, conducted intracranially via a tailored extended burr-hole craniotomy, and anastomosed to a recipient M3 vessel. RESULTS: The postoperative course of both patients was uneventful in terms of cerebral ischemia or bleeding complications. In both patients, postoperative angiographic controls revealed an excellent bypass function with markedly improved hemispheric filling of multiple middle cerebral artery branches. The patients were discharged without new neurological symptoms. CONCLUSION: Our extracranial posterior communicating artery bypass using a radial artery transplant from the vertebral artery to the middle cerebral artery is a useful tool to treat patients suffering from hemodynamic cerebrovascular compromise caused by common carotid artery occlusion.

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