Geometric Reconstruction of the Carotid Bulb: Modified Great Saphenous Vein Interposition for Complex Carotid Artery...

Standard carotid endarterectomy techniques may be insufficient for complex carotid artery disease involving high bifurcation, extensive distal plaque, or in-stent restenosis. We describe a modified autologous great saphenous vein (GSV) interposition technique focusing on geometric reconstruction and present its midterm outcomes.

Between January 2016 and December 2021, 26 patients with complex carotid disease underwent modified GSV interposition grafting. To manage the caliber mismatch between the common and distal internal carotid arteries, a "Hybrid Anastomotic Configuration" was employed, resulting in a "tapered" geometry to optimize flow dynamics. A routine nonshunting strategy under induced hypertension was adopted for all cases.

The mean patient age was 66.4 ± 7.9 (range: 47-82) years. Mean clamp and total operative times were 19.0 ± 3.0 (range: 14-25) and 76.1 ± 12.4 (range: 52-100) min, respectively. With respect to early postoperative complications, a transient ischemic attack occurred in one patient (3.8%). No long-term complications were observed. During the follow-up period (mean follow-up: 54 ± 21.6 months, range: 24-90 months), significant internal carotid artery stenosis (> 50%) was detected in only one patient while the remaining 25 patients demonstrated no significant restenosis. Aneurysm formation was not observed in any patient during follow-up.

The described technique allows for the geometric reconstruction of the carotid bulb, serving as a valuable problem-solving maneuver where standard patching is technically feasible but risky, or contraindicated due to anatomical complexity. It specifically overcomes the challenges of high bifurcation and extensive plaque, ensuring precise distal control and excellent midterm patency without the long-term risks of synthetic materials.