External Carotid-to-Middle Cerebral Bypass in the Treatment of Complex Internal Carotid Injury

Abstract

Patients with penetrating carotid injuries above C2 present special challenges to the cerebrovascular surgeon. A subgroup of patients may lack the vascular collaterals necessary to tolerate carotid sacrifice or prolonged ischemia during direct carotid repair. We present a technique of extracranial-intracranial (EC-IC) saphenous vein bypass in two patients with high cervical and skull base carotid injuries and poor vascular collaterals. This technique allows preservation of internal carotid flow during the proximal anastomosis. Interruption of cerebral blood flow is limited to the duration required for a distal intracranial anastomosis and is confined to the territory supplied by a single middle cerebral branch. The procedure eliminates systemic anticoagulation, includes trapping of the injured segment of the internal carotid artery, and restores a volume of flow similar to that of the internal carotid artery. It is a valuable adjunct in this specific population of patients with high carotid injuries who cannot tolerate even brief periods of temporary occlusion or in whom clinical urgency precludes an endovascular trial occlusion.

Radial Artery Graft for Bypass of the Maxillary to Proximal Middle Cerebral Artery: An Anatomic and Technical Study

“…Blood flow through a newly established STA-to-MCA anastomosis has been reported to provide only 10 ml/100 g of additional flow, which may not be adequate to prevent ischemia (1). Procedures having the ICA or proximal MCA as the recipient of the bypass are reported to be more protective than anastomosis of the STA to the cortical branch of the MCA (6,11,12,19,21,25,29). Therefore, we decided to perform an anastomosis between the MA and proximal MCA directly when the thickness of the STA was inadequate or a higher flow graft was needed.…”

Traumatic Pseudoaneurysm of Internal Carotid Artery presenting as Intractable Epistaxis in a Case of Maxillary Fracture

“…Traumatic pseudoaneurysms located near the skull base are hazardous to approach and challenging to repair. 7 In the past, surgical treatment of ICA pseudoaneurysons has been the preferred approach; 8,9 however, the close proximity to the skull base makes repair diffi cult. The development of endovascular techniques now provides a feasible alternative to direct surgical repair for vascular injuries of the ICA near the skull base.…”

Management of Zone III Missile Injuries Involving the Carotid Artery andCranial Nerves

“…9 Since the Korean War, the management of ICA injury has evolved toward preservation of the carotid circulation, usually by direct repair or interposition grafting, where feasible, with an overall mortality of 15-20%. 1,[9][10][11][12][13][14][15] In 1973, Bradley 9 introduced the stratification of patients into revascularization versus conservative therapy based on preoperative neurological condition. His conclusion was that patients who were obtunded or comatose on initial presentation have a poor prognosis, whereas awake patients, even with hemiparesis, benefit from intervention.…”

“…[16][17][18][19] The more recent reports demonstrate good outcomes with revascularization in the stable patient, but a management algorithm based on hemodynamic and neurological status for patients with zone III injuries has not been developed. 10,[12][13][14]…”

“…In reviewing reports of EC-IC bypass for high ICA injury, hemodynamically stable patients who were treated with bypass did better than those treated with carotid occlusion/ligation or conservative medical therapy. 10,[12][13][14] The subset of hemodynamically stable patients that received "conservative therapy" (carotid sacrifice or medical therapy) had the poorest results.…”