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Carotid Bypass and Reconstruction

  • Author: Cheong Jun Lee, MD; Chief Editor: Vincent Lopez Rowe, MD  more...
 
Updated: Nov 25, 2014
 

Background

Direct reconstruction of the cervical carotid artery by means of a surgical bypass may be indicated in situations where revascularization via endarterectomy and primary patch closure cannot be performed. Examples of such clinical scenarios, in addition to primary atherosclerotic occlusion, include the following:

  • Primary and secondary (traumatic or mycotic) aneurysmal degeneration of the cervical carotid artery that is not amenable to endovascular therapy
  • Redo carotid operations after failed endarterectomy
  • Severe long-segment radiation arteritis that is not amenable to endovascular therapy
  • Malignant invasion of the carotid artery that warrants resection and reconstruction
  • Revascularization before treatment of an aortic arch aneurysm via endovascular coverage of an arch vessel origin
  • Infected carotid patches that call for excision and reconstruction

The morbidity of carotid bypasses is higher than that observed in primary carotid endarterectomy (CEA) with regard to rates of stroke (0.5-8%) and nerve injury (up to 10%).[1, 2, 3, 4, 5, 6] The bulk of these cases involve reoperative situations; in addition, a more extensive and difficult neck dissection is required for certain pathologic conditions involving the cervical carotid artery (ie, malignancy and radiation exposure).

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Indications

Indications for carotid bypass and reconstruction are as follows:

  • Long-segment atherosclerotic stenosis or occlusion
  • Aneurysmal disease
  • Infection of a previously placed prosthetic carotid patch
  • Malignant invasion
  • Radiation arteritis
  • Recurrent stenosis after a previous endarterectomy that is not amenable to endovascular therapy; a study by Spinelli et al suggests that carotid bypass may be superior to carotid angioplasty and stenting (CAS) or redo CEA for post-CEA restenosis or for intrastent restenosis after CAS for post-CEA restenosis [7]
  • Elective debranching (revascularization) of an arch vessel in lieu of aortic arch stenting or surgery
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Contraindications

Contraindications for carotid bypass and reconstruction are as follows:

  • Debilitated patient with severe comorbidities
  • Lack of an appropriate distal target for revascularization (intracranial extension)
  • Unaddressed inflow disease
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Technical Considerations

Relevant anatomy

The principal arteries supplying the head and neck are the two common carotid arteries (CCAs). These vessels ascend in the neck, where each divides into two branches, the external carotid artery (ECA, which supplies the exterior of the head, the face, and the greater part of the neck) and the internal carotid artery (ICA, which supplies to a great extent the parts within the cranial and orbital cavities). (See Arterial Supply Anatomy and Arteries to the Brain and Meninges.)

Procedural planning

The approach to reconstructing the carotid artery depends largely on the etiology of the disease and the anatomic level of the lesion being treated. A thorough history and a careful physical examination should be performed to assess baseline cranial nerve and functional neurologic status.

In general, if wound healing and infection are not significant concerns, a prosthetic bypass graft should be used rather than autogenous vein because restenosis rates are lower.[2] If wound healing issues are encountered, as in the case of infection or irradiated tissue, the need for well-vascularized muscular flaps should be anticipated to cover the reconstruction.

For reoperations, the approach is generally different from the one used for conventional CEA. The basic principle of the bypass is to place the distal anastomosis into a previously undissected and disease-free area of the CCA or the ICA, avoiding dissection of and potential injury to the cranial nerves.

Preoperative planning is essential, and characterization of the inflow vessel (aorta, subclavian artery, ipsilateral CCA, or contralateral CCA) and the distal target by means of computed tomographic angiography (CTA) or magnetic resonance angiography (MRA) must be performed. Carotid angiography may be an important adjunct for preoperative assessment; however, important anatomic relations to bony and soft tissue structures are better characterized with CTA or MRA.

Defining the extent of the reconstruction preoperatively helps the surgeon determine whether additional exposure (eg, median sternotomy and mandibular subluxation) is likely to be necessary.

Complication prevention

The following measures should be employed to help prevent complications:

  • Careful preoperative assessment of cranial nerves and neurologic examination
  • Thorough preoperative assessment of the inflow and target vessels, the anatomic extent of the lesion, and the lesion’s relations to surrounding structures
  • Strict attention to sterile technique in the handling of prosthetic grafts
  • Systemic heparinization of patients with a target activated clotting time (ACT) longer than 250 sec before the clamping of the vessels and after the completion of graft tunneling
  • Judicious use of shunts
  • Preparation to assess the reconstruction at the time of the operation by means of duplex ultrasonography or intraoperative arteriography
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Contributor Information and Disclosures
Author

Cheong Jun Lee, MD Assistant Professor of Surgery, Division of Vascular Surgery, Medical College of Wisconsin

Cheong Jun Lee, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, Association for Academic Surgery, Michigan State Medical Society, Society for Vascular Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

Mark D Morasch, MD, RPVI Vascular Surgeon, Section Head of Vascular and Endovascular Services, Billings Clinic; John Marquardt Clinical Research Professor in Vascular Surgery, Division of Vascular Surgery, Northwestern University, The Feinberg School of Medicine

Mark D Morasch, MD, RPVI is a member of the following medical societies: Society for Vascular Surgery, Western Surgical Association, Southern Association for Vascular Surgery, American Venous Forum, Vascular and Endovascular Surgery Society, Society for Clinical Vascular Surgery, Western Vascular Society, Midwestern Vascular Surgical Society, American College of Surgeons, American Medical Association, American Heart Association, Central Surgical Association, Western Vascular Society, Southern Association for Vascular Surgery

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Society for Vascular Surgery, Vascular and Endovascular Surgery Society, Society for Clinical Vascular Surgery, Pacific Coast Surgical Association, Western Vascular Society

Disclosure: Nothing to disclose.

Acknowledgements

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References
  1. Zhou W, Lin PH, Bush RL, Peden E, Guerrero MA, Terramani T. Carotid artery aneurysm: evolution of management over two decades. J Vasc Surg. 2006 Mar. 43(3):493-6; discussion 497. [Medline].

  2. Lauder C, Kelly A, Thompson MM, London NJ, Bell PR, Naylor AR. Early and late outcome after carotid artery bypass grafting with saphenous vein. J Vasc Surg. 2003 Nov. 38(5):1025-30. [Medline].

  3. Naughton PA, Garcia-Toca M, Rodriguez HE, Pearce WH, Eskandari MK, Morasch MD. Carotid artery reconstruction for infected carotid patches. Eur J Vasc Endovasc Surg. 2010 Oct. 40(4):492-8. [Medline].

  4. Sessa CN, Morasch MD, Berguer R, Kline RA, Jacobs JR, Arden RL. Carotid resection and replacement with autogenous arterial graft during operation for neck malignancy. Ann Vasc Surg. 1998 May. 12(3):229-35. [Medline].

  5. Berguer R, Morasch MD, Kline RA, Kazmers A, Friedland MS. Cervical reconstruction of the supra-aortic trunks: a 16-year experience. J Vasc Surg. 1999 Feb. 29(2):239-46; discussion 246-8. [Medline].

  6. Berguer R, Morasch MD, Kline RA. Transthoracic repair of innominate and common carotid artery disease: immediate and long-term outcome for 100 consecutive surgical reconstructions. J Vasc Surg. 1998 Jan. 27(1):34-41; discussion 42. [Medline].

  7. Spinelli F, Martelli E, Stilo F, Pipitò N, Benedetto F, Spinelli D, et al. Carotid bypass: a safe and durable solution for recurrent carotid stenosis. Ann Vasc Surg. 2014 Jul. 28(5):1329-34. [Medline].

  8. Roddy SP, Darling RC 3rd, Ozsvath KJ, Mehta M, Chang BB, Paty PS. Choice of material for internal carotid artery bypass grafting: vein or prosthetic? Analysis of 44 procedures. Cardiovasc Surg. 2002 Dec. 10(6):540-4. [Medline].

 
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CT scan demonstrating CCA-to-CCA bypass using retropharyngeal route. CCA = common carotid artery; PTFE = polytetrafluoroethylene (bypass graft).
Aorta-to-CCA bypass using 8-mm Dacron graft. AA = ascending aortic arch; CCA = common carotid artery.
CCA-to-ICA reconstruction with 6-mm PTFE graft, performed for aneurysmal disease of carotid bifurcation. CCA = common carotid artery; ECA = external carotid artery; ICA = internal carotid artery; IJ = internal jugular vein; PTFE = polytetrafluoroethylene.
ICA is shunted during CCA-to-ICA bypass. CCA = common carotid artery; ICA = internal carotid artery.
 
 
 
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