CAR 10. Endarterectomy for Acute Symptomatic Thrombotic Occlusion of the Entire Extracranial Internal Carotid Artery: A Case Report

Abstract

We report the case of a 60-year-old woman who was admitted with a sudden onset of numbness of the left upper extremity. Two weeks before admission, the patient presented with a right hemispheric transient ischemic attack and temporary right facial paresis. Duplex ultrasound and magnetic resonance (MR) angiography revealed an occlusion of the right internal carotid artery (ICA) as well as a high-grade stenosis of the left ICA with patency of the cerebral arteries (middle cerebral artery [MCA]). A cranial computed tomography scan showed a small hypodense lesion of the right hemisphere and several lacunar infarctions without signs of intracranial bleeding. An exploration of the right carotid bifurcation was performed, and an atherosclerotic plaque at the carotid bifurcation with a fresh clot downstream was found. Thrombectomy was performed using a 2F balloon catheter, resulting in a sufficient backflow from the ICA. In addition, thromboendarterectomy with patch plasty was performed. On the final intraoperative angiogram, the entire right ICA and the downstream intracranial vessels were patent. Intraoperative duplex ultrasound confirmed a sufficient hemodynamic profile without major turbulences. The postoperative MR angiogram confirmed patency of the ICA with an undisturbed perfusion of the right hemisphere. The postoperative course was uneventful; no neurologic symptoms occurred, and she was discharged on postoperative day 8. Six weeks later, the left ICA stenosis (North American Symptomatic Carotid Endarterectomy Trial [NASCET] 90%) was treated successfully by conventional thromboendarterectomy. During follow-up of 61 months, no neurologic or cardiac events occurred. A recurrent ICA stenosis was not detected. Comparing the perfusion of the right MCA with the preoperative MR angiogram, we conclude that a sufficient blood supply to the right MCA could probably not have been achieved by a simple left-sided carotid thromboendarterectomy. Whereas chronic ICA occlusion is generally accepted as a condition not suitable for extracranial reconstruction, our patient profited from revascularization as she suffered from an acute occlusion on top of a chronic stenosis. It remains uncertain which occluded artery should be explored and, specifically, at what time. In symptomatic patients, exploration of the ICA and carotid bifurcation might be justified to restore blood flow and to prevent a severe stroke event.