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Carotid cross-over bypass. Cerebral revascularization after ligation of common carotid artery
Insights
Extra-anatomic carotid cross-over bypass offers a solution for restoring blood flow to the internal carotid artery after common carotid artery disruption. This technique successfully treated a patient with hemiplegia, leading to functional recovery.
Area of Science:
- Vascular Surgery
- Cerebrovascular Surgery
- Surgical Innovation
Background:
- Disruption and ligation of the common carotid artery can compromise internal carotid artery (ICA) blood flow.
- Infection spread is anatomically limited cephalad by the carotid sheath's attachment to the hyoid bone.
- Cerebral revascularization is crucial in cases of post-operative neurological deficits.
Observation:
- A patient presented with an infected, disrupted right common carotid artery and an esophageal fistula, requiring double ligation.
- Post-ligation, the patient developed contralateral hemiplegia, necessitating urgent cerebral revascularization.
- Carotid angiography revealed patent ipsilateral cerebral vessels and retrograde filling of the right ICA to the bifurcation.
Findings:
- Extra-anatomic carotid cross-over bypass, specifically external carotid to external carotid vein bypass, was deemed technically feasible.
- The suprahyoid bypass approach avoids operating within the infected surgical field.
- The procedure resulted in prompt recovery of neurological function.
Implications:
- This surgical strategy provides a viable option for managing complex carotid artery injuries where direct reconstruction is contraindicated.
- Extra-anatomic bypass can effectively restore cerebral perfusion and prevent ischemic complications.
- The suprahyoid location offers a safe alternative for revascularization in infected neck wounds.
Abstract:
A rationale is presented for extra-anatomic carotid cross-over bypass to maintain or restore blood flow to the internal carotid artery distal to sites of disruption and ligation of a common carotid artery. Anatomic evidence indicates that the attachment of the carotid sheath to the hyoid bone is a barrier to spread of infection cephalad to that level. A patient with infected and disrupted right common carotid artery associated with an esophageal fistula was treated by double ligation of the artery. Contralateral hemiplegia 48 hours later forced consideration of cerebral revascularization. Left carotid angiography demonstrated patent cerebral vessels on the right, with retrograde filling of the right internal carotid artery to the bifurcation. These findings were interpreted as consistent with technical feasibility of external carotid to external carotid cross-over vein bypass in a suprahyoid location, avoiding reconstruction in an infected area and resulting in prompt recovery of function.