Distal Cervical Carotid Dissection after Carotid Endarterectomy: A Complication of Indwelling Shunt?

Abstract

Technical factors and surgical techniques in carotid endarterectomy remain a controversial subject. The use of an indwelling arterial shunt has theoretical advantages in assuring intraoperative hemispheric perfusion and affording a more relaxed surgical environment. There has been little clinical demonstration, however, of superior results with carotid shunting. Although champions of routine shunting argue that it is a benign protective intervention, the possibilities of distal embolization or intimal disruption exist. The authors report a case of cervical carotid dissection far distal to the operative site that they postulate resulted from intimal disruption after routine shunt placement. This devastating complication from an otherwise benign procedure prompts reconsideration of the benefits and risks of routine shunt placement.

Examination of regional anesthesia for carotid endarterectomy

“…9,10 On the contrary, the most common surgery-related indications for conversion to general anesthesia are loss of consciousness at carotid clamping and shunt-related complications (inadequate perfusion, air or plaque embolization, mechanical damage during shunt insertion or removal). 11,12 In our study, restlessness and agitation, probably due to block failure or claustrophobia, were the most common reasons for conversion to general anesthesia (4 of 2463 of cases). Similar incidences of block failure were reported in other studies.…”

A case of traumatic internal carotid artery aneurysm secondary to carotid shunting

“…These rare complications are familiar to vascular surgeons but are infrequently described in the literature. 1,5,6 This report describes a previously unreported complication, to our knowledge, of carotid shunting: an aneurysm of the distal internal carotid artery (ICA) at the site of shunt placement.…”

Distal Cervical Carotid Artery Dissection after Carotid Endarterectomy: A Complication of Indwelling Shunt

“…Cervical carotid artery dissection is often spontaneous or idiopathic, but it is also associated with trauma to the carotid arteries and with catheterization (as in percutaneous carotid angiography) [5–8]. The mechanism of injury in these latter cases is presumed to be an intimal tear that allows a new dissection plane to be established in the arterial wall [5–7]. Intraoperative use of an indwelling shunt may cause direct injury to the arterial wall.…”

“…Potential complications of shunt placement include particulate embolization of atheromatous material, either distal to the shunt tip or through the shunt itself, as well as intimal damage that may lead to carotid dissection [1–4]. Although the latter possibility has been raised by numerous authors, we are aware of only one case in which distal carotid artery dissection was documented as being due to a shunt [5]. We present another rare case of internal carotid artery dissection caused by an indwelling arterial shunt.…”