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A technical improvement in retropharyngeal carotid reconstruction
A technical improvement in retropharyngeal carotid reconstruction José María Egaña, MD, Javier Sánchez, MD, Víctor Rodríguez, MD, Ainhoa García, MD, Mariano De Blas, MD, and Francisco Ortiz, MD, San Sebastián, Spain The carotid– carotid bypass via a retropharyngeal tunnel enables treating proximal occlusions. With reference to two clinical cases, we present a technique that consists of transposition of one of the carotid arteries to contralateral position, avoiding simultaneous clamping of both carotids. ( J Vasc Surg 2012;56:542-4.)
Reconstruction of supra-aortic trunks is used in both occlusive lesions and debranching procedures to treat lesions of the aortic arch. With regard to carotid– carotid bypasses, the retropharyngeal route is the shortest. The conduit employed can be either a graft or the artery itself. The latter involves clamping of both carotids simultaneously and so a shunt is required. This report presents a technique that consists of transposition of the contralateral carotid artery avoiding simultaneous clamping of both carotids, providing they are elongated enough. CASE REPORTS Case 1. A 76-year-old male was transferred to our unit after being diagnosed as having a saccular aneurysm of the aortic arch. His medical history was notable for arterial hypertension, dyslipidemia, bullous pemphigoid, spontaneous pneumothorax, prostatectomy, and inguinal hernia repair. Endovascular treatment of the aneurysm was planned. Bearing in mind that this was located in zone 1 of the aortic arch, revascularization of the left carotid artery was required to provide a landing zone for endovascular repair.1 Treatment was performed in two stages. In the first stage, the left carotid artery was transposed to the right via a retropharyngeal tunnel. During right carotid clamping for 12 minutes, this was completely sectioned, reimplanting the distal segment in the proximal end-to-side and leaving a sleeve to anastomose the left carotid artery. Afterwards, the right carotid was unclamped and during left carotid clamping for 22 minutes, this was sectioned as proximal as possible and was anastomosed end-to-end to the sleeve in the right carotid artery (Fig 1). This procedure could be carried out if the patient’s carotid arteries were long enough. Six days later, the second stage was completed excluding the aneurysm with a 30 mm ⫻ 30 cm Medtronic stent graft (Medtronic, Santa Rosa, Calif) (Figs 2 and 3). Occlusion of the left subclavian artery was well tolerated and the patient was discharged 13 days after the From the Hospital Donostia. Author conflict of interest: none. Reprint requests: Víctor Rodríguez, MD, Hospital Donostia, Catalina de Erauso 73D, 20010 San Sebastián, Spain (e-mail: victor.rodriguezsaenzdeburuaga@ osakidetza.net). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214/$36.00 Copyright © 2012 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2012.03.019
542
Fig 1. Reimplantation of the left carotid in the right carotid.
Fig 2. Arteriography before endovascular treatment.
first procedure. At 36-month follow-up, the patient was asymptomatic,2 had not suffered complications of any kind, and a reduction in the diameter of the aneurysm had been proven.
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Egaña et al 543
Fig 3. Arteriography after endoprosthesis colocation.
Case 2. A 76-year-old female, who had been treated for a thoracic aneurysm with an endoprosthesis 15 months earlier, was diagnosed in the follow-up as having a type I proximal leak. Placement of an endoprosthesis both proximal to the previous one and immediately distal to the brachiocephalic trunk was planned. In the first stage, as described in the previous case, the left carotid artery was transposed to the right via a retropharyngeal tunnel. Clamping times were 10 minutes for the right carotid artery and 16 for the left carotid artery. Later, a left carotid–subclavian bypass with a 7-mm-polytetrafluoroethylene graft was performed.3 In the second stage, sealing of the proximal type I endoleak (Fig 4) was achieved with the deployment of a 40-mm ⫻ 20-cm Medtronic-Valiant endoprosthesis (Medtronic, Galway, Ireland). Immediate postoperative recovery was satisfactory and at 1-month follow-up, the patient is complication-free.
DISCUSSION The retropharyngeal approach has been described4 and its results were reported in a previous series.5 Advantages of this technique are well known. Not only is it the shortest route, but it also offers the best protection to the bypass avoiding surrounding the trachea.2 On the other hand, a major drawback could be contact between the prosthesis and the digestive tract, taking the chance of eroding it.5 Transposing one of the carotid arteries to the contralateral would be an alternative. Despite not using a graft, this procedure implies simultaneous clamping of both carotid arteries and, therefore, a shunt is required to decrease the risk of neurologic events.4,5 Lastly, we do not always have a suitable vein, which would avoid having to use a graft. We describe a technique to implant one of the carotids in the contralateral, avoiding simultaneous clamping of both carotid arteries. During the reconstruction of the
Fig 4. Reimplantation of the left carotid in the right carotid and polytetrafluoroethylene 7-mm bypass of the primitive left carotid artery to the left subclavian artery.
donor carotid artery, we leave a sleeve to receive the contralateral carotid artery while cerebral perfusion is maintained through the left carotid artery. After unclamping the right carotid and occluding only the sleeve to avoid bleeding, clamping of the left carotid is balanced by the right carotid that is now responsible for maintaining cerebral perfusion. This way, we achieve our aim of avoiding simultaneous clamping of both carotid arteries. Moreover, as the second case shows, this technique also enables revascularization of the left subclavian artery, preserving the advantages of a retropharyngeal tunnel with a native artery. This technique has some limitations. Enough elongation of carotid arteries, especially the donor one, is mandatory to enable reconstruction, leaving a sleeve to receive the contralateral carotid artery. Therefore, it can only be applied in selected cases in which carotid arteries are elongated enough. Additional revascularization of left subclavian artery could be another possible flaw in this technique. However, as the second case shows, this can be performed without additional technical complexity. Therefore, we consider that, provided the carotids are elongated enough, this is a useful technique for nonanatomic revascularization of the supra-aortic trunks. REFERENCES 1. Mitchell RS, Ishimaru S, Ehrlich MP, Iwase T, Lauterjung L, Shimono T, et al. First international summit on thoracic aortic endografting: round table on thoracic aortic dissection as an indication for endografting. J Endovasc Ther 2002;9(Suppl II):98-II105.
544 Egaña et al
2. Ozsvath KJ, Roddy SP, Darling RC III, Byrne J, Kreienberg PB, Choi D, et al. Carotid-carotid crossover bypass: is it a durable procedure? J Vasc Surg 2003;37:582-5. 3. Vallabhaneni R, Sanchez, LA. Open techniques for arch vessel reconstruction during thoracic endovascular aneurysm repair (TEVAR). J Vasc Surg 2010;52:71S-6S.
JOURNAL OF VASCULAR SURGERY August 2012
4. Berguer R. The short retropharyngeal route for arterial bypass across the neck. Ann Vasc Surg 1986;1:127-9. 5. Berguer R, Gonzalez JA. Revascularization by the retropharyngeal route for extensive disease of the extracranial arteries. J Vasc Surg 1994;19: 217-24. Submitted Dec 2, 2011; accepted Mar 5, 2012.
Reconstruction of supra-aortic trunks is used in both occlusive lesions and debranching procedures to treat lesions of the aortic arch. With regard to carotid– carotid bypasses, the retropharyngeal route is the shortest. The conduit employed can be either a graft or the artery itself. The latter involves clamping of both carotids simultaneously and so a shunt is required. This report presents a technique that consists of transposition of the contralateral carotid artery avoiding simultaneous clamping of both carotids, providing they are elongated enough. CASE REPORTS Case 1. A 76-year-old male was transferred to our unit after being diagnosed as having a saccular aneurysm of the aortic arch. His medical history was notable for arterial hypertension, dyslipidemia, bullous pemphigoid, spontaneous pneumothorax, prostatectomy, and inguinal hernia repair. Endovascular treatment of the aneurysm was planned. Bearing in mind that this was located in zone 1 of the aortic arch, revascularization of the left carotid artery was required to provide a landing zone for endovascular repair.1 Treatment was performed in two stages. In the first stage, the left carotid artery was transposed to the right via a retropharyngeal tunnel. During right carotid clamping for 12 minutes, this was completely sectioned, reimplanting the distal segment in the proximal end-to-side and leaving a sleeve to anastomose the left carotid artery. Afterwards, the right carotid was unclamped and during left carotid clamping for 22 minutes, this was sectioned as proximal as possible and was anastomosed end-to-end to the sleeve in the right carotid artery (Fig 1). This procedure could be carried out if the patient’s carotid arteries were long enough. Six days later, the second stage was completed excluding the aneurysm with a 30 mm ⫻ 30 cm Medtronic stent graft (Medtronic, Santa Rosa, Calif) (Figs 2 and 3). Occlusion of the left subclavian artery was well tolerated and the patient was discharged 13 days after the From the Hospital Donostia. Author conflict of interest: none. Reprint requests: Víctor Rodríguez, MD, Hospital Donostia, Catalina de Erauso 73D, 20010 San Sebastián, Spain (e-mail: victor.rodriguezsaenzdeburuaga@ osakidetza.net). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214/$36.00 Copyright © 2012 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2012.03.019
542
Fig 1. Reimplantation of the left carotid in the right carotid.
Fig 2. Arteriography before endovascular treatment.
first procedure. At 36-month follow-up, the patient was asymptomatic,2 had not suffered complications of any kind, and a reduction in the diameter of the aneurysm had been proven.
JOURNAL OF VASCULAR SURGERY Volume 56, Number 2
Egaña et al 543
Fig 3. Arteriography after endoprosthesis colocation.
Case 2. A 76-year-old female, who had been treated for a thoracic aneurysm with an endoprosthesis 15 months earlier, was diagnosed in the follow-up as having a type I proximal leak. Placement of an endoprosthesis both proximal to the previous one and immediately distal to the brachiocephalic trunk was planned. In the first stage, as described in the previous case, the left carotid artery was transposed to the right via a retropharyngeal tunnel. Clamping times were 10 minutes for the right carotid artery and 16 for the left carotid artery. Later, a left carotid–subclavian bypass with a 7-mm-polytetrafluoroethylene graft was performed.3 In the second stage, sealing of the proximal type I endoleak (Fig 4) was achieved with the deployment of a 40-mm ⫻ 20-cm Medtronic-Valiant endoprosthesis (Medtronic, Galway, Ireland). Immediate postoperative recovery was satisfactory and at 1-month follow-up, the patient is complication-free.
DISCUSSION The retropharyngeal approach has been described4 and its results were reported in a previous series.5 Advantages of this technique are well known. Not only is it the shortest route, but it also offers the best protection to the bypass avoiding surrounding the trachea.2 On the other hand, a major drawback could be contact between the prosthesis and the digestive tract, taking the chance of eroding it.5 Transposing one of the carotid arteries to the contralateral would be an alternative. Despite not using a graft, this procedure implies simultaneous clamping of both carotid arteries and, therefore, a shunt is required to decrease the risk of neurologic events.4,5 Lastly, we do not always have a suitable vein, which would avoid having to use a graft. We describe a technique to implant one of the carotids in the contralateral, avoiding simultaneous clamping of both carotid arteries. During the reconstruction of the
Fig 4. Reimplantation of the left carotid in the right carotid and polytetrafluoroethylene 7-mm bypass of the primitive left carotid artery to the left subclavian artery.
donor carotid artery, we leave a sleeve to receive the contralateral carotid artery while cerebral perfusion is maintained through the left carotid artery. After unclamping the right carotid and occluding only the sleeve to avoid bleeding, clamping of the left carotid is balanced by the right carotid that is now responsible for maintaining cerebral perfusion. This way, we achieve our aim of avoiding simultaneous clamping of both carotid arteries. Moreover, as the second case shows, this technique also enables revascularization of the left subclavian artery, preserving the advantages of a retropharyngeal tunnel with a native artery. This technique has some limitations. Enough elongation of carotid arteries, especially the donor one, is mandatory to enable reconstruction, leaving a sleeve to receive the contralateral carotid artery. Therefore, it can only be applied in selected cases in which carotid arteries are elongated enough. Additional revascularization of left subclavian artery could be another possible flaw in this technique. However, as the second case shows, this can be performed without additional technical complexity. Therefore, we consider that, provided the carotids are elongated enough, this is a useful technique for nonanatomic revascularization of the supra-aortic trunks. REFERENCES 1. Mitchell RS, Ishimaru S, Ehrlich MP, Iwase T, Lauterjung L, Shimono T, et al. First international summit on thoracic aortic endografting: round table on thoracic aortic dissection as an indication for endografting. J Endovasc Ther 2002;9(Suppl II):98-II105.
544 Egaña et al
2. Ozsvath KJ, Roddy SP, Darling RC III, Byrne J, Kreienberg PB, Choi D, et al. Carotid-carotid crossover bypass: is it a durable procedure? J Vasc Surg 2003;37:582-5. 3. Vallabhaneni R, Sanchez, LA. Open techniques for arch vessel reconstruction during thoracic endovascular aneurysm repair (TEVAR). J Vasc Surg 2010;52:71S-6S.
JOURNAL OF VASCULAR SURGERY August 2012
4. Berguer R. The short retropharyngeal route for arterial bypass across the neck. Ann Vasc Surg 1986;1:127-9. 5. Berguer R, Gonzalez JA. Revascularization by the retropharyngeal route for extensive disease of the extracranial arteries. J Vasc Surg 1994;19: 217-24. Submitted Dec 2, 2011; accepted Mar 5, 2012.