Management of Severe Bilateral Symptomatic Internal Carotid Artery Stenosis: Case Report and Literature Review

Prior research has shown that the management of severe bilateral internal carotid artery stenosis remains one of the most controversial topics in vascular surgery due to the high risk of periprocedural stroke. Clinicians must navigate the complex physiological demands of revascularizing two major vessels while avoiding the catastrophic consequences of cerebral hyperperfusion syndrome and hemodynamic instability. Existing literature describes various strategies including bilateral Carotid Artery Endarterectomy (CEA), bilateral Carotid Artery Stenting (CAS), or a hybrid combination of these two modalities. The physiological stress of these procedures is compounded by the potential for significant blood pressure fluctuations and the risk of myocardial ischemia in patients with concurrent coronary artery disease. Many surgeons hesitate to perform bilateral procedures within a short timeframe because of the perceived danger of bilateral cranial nerve injuries or uncontrolled cerebral edema. The lack of standardized guidelines for the optimal interval between sequential surgeries often leads to prolonged hospital stays or delayed treatment for critical lesions. This absence of evidence motivated the exploration of a rapid three-day staging protocol for a patient with symptomatic high-grade narrowing.

This clinical report details the successful implementation of a staged surgical revascularization protocol for a sixty-four-year-old patient presenting with critical bilateral carotid narrowing. The primary objective was to address a ninety-five percent stenosis in the left internal carotid artery and a ninety percent stenosis in the right internal carotid artery. Researchers aimed to demonstrate that a three-day interval between sequential Carotid Artery Endarterectomy (CEA) procedures could be safely managed in a symptomatic individual. The study specifically examines the management of a patient who had already suffered recent watershed strokes in the anterior cerebral artery-medial cerebral artery (ACA-MCA) and medial cerebral artery-posterior cerebral artery (MCA-PCA) regions. By documenting the specific intraoperative protection measures and postoperative monitoring, the authors provide a framework for treating tandem lesions in high-risk surgical candidates. The investigation also highlights the importance of coordinating care between multiple medical specialties to ensure cardiovascular and neurological stability. This case serves to illustrate that an accelerated surgical timeline may prevent further ischemic events in patients with unstable neurological symptoms.

The surgical team performed two separate Carotid Artery Endarterectomy (CEA) procedures under general anesthesia with a seventy-two-hour recovery period between the interventions. Intraoperative brain protection was prioritized by evaluating carotid stump pressure and internal carotid backflow to determine the necessity of a temporary shunt. Continuous monitoring of cerebral oxygenation was maintained using Near-Infrared Spectroscopy (NIRS) to detect any significant drops in hemispheric perfusion during arterial clamping. For the arterial reconstruction, surgeons utilized a specialized collagen and silver-coated polyester patch to ensure a durable and infection-resistant closure of the vessel. The patch was meticulously secured using a 6.0 polypropylene continuous suture to maintain the integrity of the internal carotid lumen. Postoperative care involved immediate neurological consultations after extubation and the initiation of dual antiplatelet therapy to prevent thromboembolic complications. A non-contrast head Computed Tomography (CT) scan was performed between the first and second surgeries to confirm the absence of intracranial hemorrhage or new infarcts.

The staged surgical approach successfully eliminated a ninety-five percent stenosis in the left internal carotid artery and a ninety percent narrowing in the contralateral vessel. Preoperative diagnostic imaging had identified recent ipsilateral watershed strokes involving the anterior cerebral artery-medial cerebral artery (ACA-MCA) and medial cerebral artery-posterior cerebral artery (MCA-PCA) junctions. Despite the patient's history of coronary angioplasty and stenting, no episodes of myocardial ischemia were detected during the perioperative monitoring period. The use of Near-Infrared Spectroscopy (NIRS) and stump pressure measurements provided reliable data that guided the successful placement of intraoperative shunts in both procedures. Neurological assessments conducted after each surgery confirmed that the patient did not experience any new focal deficits or symptoms of cerebral hyperperfusion syndrome. The collagen and silver-coated polyester patches maintained excellent structural integrity with no evidence of suture line bleeding or acute thrombosis. The patient was successfully discharged following the completion of the staged interventions without any significant hemodynamic distress or surgical site complications.

Staged Carotid Artery Endarterectomy (CEA) with a brief three-day interval is a feasible therapeutic option for managing tandem symptomatic carotid artery stenosis in carefully selected patients. The success of this case suggests that rapid sequential revascularization can effectively prevent further ischemic strokes while minimizing the risks associated with prolonged waiting periods. Clinical decisions regarding the management of bilateral high-grade lesions must be tailored to the specific anatomical and physiological profile of the individual patient. A multidisciplinary team comprising cardiology specialists, neurology experts, and anesthesia and intensive care physicians is essential for optimizing perioperative outcomes. This collaborative approach ensures that potential complications such as hemodynamic instability or myocardial ischemia are identified and managed promptly. The findings underscore the importance of utilizing advanced intraoperative monitoring tools like Near-Infrared Spectroscopy (NIRS) to enhance the safety of bilateral surgical interventions. Future clinical studies are needed to further refine the selection criteria for patients who would benefit most from an accelerated staged surgical protocol.