Peripheral Vascular Surgery Society
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Peripheral Vascular Surgery Society |
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#18 CHRONIC CAROTID DISSECTION PRODUCING NEW NEUROLOGIC SYMPTOMS: AN ALTERNATIVE METHOD OF AUTOGENOUS RECONSTRUCTION
Catherine M. Wittgen, MD St. Louis University Hospital St. Louis, MO Boston, MA
A 49-year-old man was referred after several episodes of transient left eye blindness. His past medical history was remarkable for a high-speed motor vehicle accident 2 years previously, a right carotid endarterectomy 1 year prior to this presentation, hypertension and a history of tobacco use.
His physical examination was remarkable for a left carotid bruit and varicose veins. Arteriography revealed a severe distal left internal carotid artery stenosis at the level of the C1-2 interspace. On careful questioning, the patient remembered persistent left neck pain and a sensation of fullness in the left ear after his car accident.
A standard carotid dissection was performed with jaw subluxation and EEG monitoring. The distal internal carotid artery was quite small and densely adherent to the surrounding structures. Arteriotomy revealed a fibrous intimal lesion with a short segment of distal dissection. Because of the small nature of the vessel and chronic inflammatory changes, standard endarterectomy was unable to be performed. The occipital artery, which had been identified on preoperative arteriography, was then anastamosed to the distal internal carotid artery in an end-to-end fashion and the proximal internal carotid artery oversewn at the level of the bifurcation. He awakened without neurologic deficit and was discharged 18 hours postoperatively. He has had no further symptoms in the 6 months since operation.
The new development of neurologic symptoms is a rare late sequelae of carotid arterial injury. The very distal nature of the arterial injury makes surgical repair of these lesions difficult. Interposition grafting or standard endarterectomy, when an adequate distal endpoint can be visualized, usually provides adequate treatment for most extracranial lesions. The arterial reconstruction described has not previously been reported and provides a suitable alternative for patients with a small distal vessel and inadequate saphenous vein.
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Last updated January 10, 1999