IP095. Severe Tandem Carotid Lesions in an Irradiated Field with Tracheostomy and Contralateral Carotid Occlusion and Contraindication to Carotid Artery Stenting

Abstract

This is a case report and literature review of a patient with severe tandem carotid lesions in an irradiated field after radical neck dissection with tracheostomy, contralateral carotid occlusion, and contraindication to carotid artery stenting. We conducted a systematic review of the English language literature with information on severe tandem carotid lesions in a hostile field (previous surgical intervention, irradiation) and contralateral carotid occlusion. We present the case of a 71-year-old woman with asymptomatic, severe carotid artery stenosis and a past medical history significant for laryngeal cancer status post laryngectomy with stoma, radical neck dissection, and neck irradiation. Aortic arch and carotid angiography demonstrated a left internal carotid artery (ICA) occlusion, right common carotid artery (CCA) stenosis of 80%, right ICA stenosis of 50% to 60% with severe tortuosity, and occluded right external carotid artery. Given the severe ICA tortuosity with tandem lesions, carotid artery stenting was not feasible, and we proceeded with carotid endarterectomy, ICA resection, and primary anastomosis. Intraoperatively, the ICA was mobilized and the proximal ICA was resected, thus addressing the tortuosity and the distal tandem lesion. For the proximal tandem lesion located in the CCA, we performed a standard endarterectomy of the proximal portion of the CCA lesion and an eversion endarterectomy of the distal transected CCA. Next, we performed an end-to-end anastomosis of the ICA to the CCA. This was completed with a Sundt shunt in place, given the contralateral ICA occlusion. Postoperatively, the patient has done well and continues to be free of any complication, with duplex ultrasound demonstrating patency. After a thorough literature review, it is clear that this in an unusual case with a novel solution. The patient’s prior radical neck dissection with tracheostomy and irradiation would generally have made her an ideal candidate for carotid artery stenting. However, the patient was at high risk for carotid artery stenting, given the tortuosity and tandem lesions. The literature provides ample data on the benefits of carotid artery stenting for carotid stenosis in hostile necks. However, there is very little information clarifying how to approach lesions in a hostile neck when they are not amenable to stenting. Our case represents a novel open carotid endarterectomy approach to tandem lesions with associated tortuosity in a hostile operative field.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)