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Online ISSN 1827-1847
Calabrese E., Rashad N., Barbera G., Quattrone C., Calabretta L., Pellegrino O.
Vascular Surgery, The National Center for Limb Salvage, Pavia, Italy
The aim of this study was to describe a hybrid endovascular technique of stent-graft of the extra-cranial carotid artery, utilizing an artero-venous shunt with flow inversion as a way to achieve cerebral protection. A 74-year-old man who suffered recurrent transient ischemic attaks (TIA), had undergone carotid endarterectomy with saphenous patch enlargement, 2 years earlier and he now developed a symptomatic pseudo-aneurysm, partially filled with soft thrombi, along the course of the saphenous vein patch. An introducer was inserted into the left carotid through a small incision at the base of the neck. It was then connected to a 2nd introducer in the femoral vein, to produce A-V shunting. The common carotid was temporarily clamped and a Wallstent was inserted in the internal carotid and across the bifurcation. The more proximal part of the pseudoaneurysm in the common carotid was covered by inserting a Wallgraft through the femoral artery, overlapping it partially with the previously inserted Wallstent. Cerebral protection during the critical part of the procedure was provided by the A-V shunt and by the inversion of flow in the left internal carotid artery. Exclusion of the pseudoaneurysm was achieved without neurological complications. A multislice volume-rendering CT-scan and an angiogram performed 1 year post-procedure confirmed patency of the sequential stents. The patient remained free of TIA episodes during a 1 year follow-up. Hybrid procedures, with direct puncture and clamping of the carotid artery, when associated with A-V shunting, can provide a safe access for high-risk carotid stent-grafting.