Response to ‘RE: How Should I Treat a Patient with a Tandem Carotid Artery Atherosclerotic Stenosis Involving the Internal Carotid Artery and the Innominate/Proximal Common Carotid Artery?’

Abstract

Barilla et al. (in this issue) report on an alternative hybrid revascularization technique for combined carotid bifurcation and common carotid artery (CCA) origin atherosclerotic disease.1Barillà D. Massara M. Volpe A. Versace P. Volpe P. Re: ‘How should I treat a patient with a tandem carotid artery atherosclerotic stenosis involving the internal carotid artery and the innominate/proximal common carotid artery?’.Eur J Vasc Endovasc Surg. 2016; 51: 313-316https://doi.org/10.1016/j.ejvs.2015.10.018Abstract Full Text Full Text PDF Scopus (2) Google Scholar The first step in their approach is the “Cormier” vein graft to bypass a reported long and calcified internal carotid lesion “unsuitable” for regular disobliteration. In this specific case, although a bypass graft may offer a solid reconstruction, I would consider the lesion location and length shown in Fig. 1B as easily accessible for standard longitudinal carotid endarterectomy with patch plasty closure. As a second step, the authors performed retrograde stenting needing to clamp the previously constructed vein graft. The essence of performing retrograde stenting of the CCA stenosis first is the option to flush and to control potential emboli due to the stenting. With surgical clamps still on the internal and external carotid artery, debris can be flushed once the arteriotomy is created. With the authors' approach, emboli will flush in the external carotid artery and may cause ischemic problems in the outflow tract. This can easily be prevented by performing stenting first.2de Borst G.J. Hazenberg C.E. How should I treat a patient with a tandem carotid artery atherosclerotic stenosis involving the internal carotid artery and the innominate/proximal common carotid artery?.Eur J Vasc Endovasc Surg. 2015; 50: 257-258Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar Further, heparinized saline solution can be flushed and left in the proximal CCA before cross clamping the distal CCA, thereby preventing stent thrombosis. In addition, we use the CCA puncture site as the distal starting point for the later arteriotomy. In the approach of Barilla et al.,1Barillà D. Massara M. Volpe A. Versace P. Volpe P. Re: ‘How should I treat a patient with a tandem carotid artery atherosclerotic stenosis involving the internal carotid artery and the innominate/proximal common carotid artery?’.Eur J Vasc Endovasc Surg. 2016; 51: 313-316https://doi.org/10.1016/j.ejvs.2015.10.018Abstract Full Text Full Text PDF Scopus (2) Google Scholar the authors need to perform a separate puncture hole, again with the potential risk of causing emboli. The use of a covered stent may offer better protection against (late) embolization. However, uncovered stents have been shown to be safe and durable in the treatment of aortic arch origin lesions.3Van de Weijer M.A. Vonken E.J. de Vries J.P. Moll F.L. Vos J.A. de Borst G.J. Technical and clinical success and long term durability of endovascular treatment for atherosclerotic aortic arch branch origin obstruction: evaluation of 144 procedures.Eur J Vasc Endovasc Surg. 2015; 50: 13-20Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Further, a covered stent does not prevent embolization per se as the initial wire crossing of the lesion and predilatation carry the highest risk of embolic debris. It is important to reaffirm that our technique is certainly not the only or perfect approach. Each surgeon may apply his own preferred combination with specific pros and cons. Each patient needs to be discussed at multidisciplinary team meeting at which the indication for tandem lesion treatment, as well as the technical steps, can be discussed. Re: ‘How Should I Treat a Patient with a Tandem Carotid Artery Atherosclerotic Stenosis Involving the Internal Carotid Artery and the Innominate/Proximal Common Carotid Artery?’European Journal of Vascular and Endovascular SurgeryVol. 51Issue 2PreviewWe read with great interest the article by de Borst et al.,1 who described a hybrid technique to simultaneously treat tandem lesions of internal carotid artery (ICA) stenosis combined with severe stenosis (> 50%) of the ipsilateral common carotid artery (CCA) origin using a single cervical incision. Full-Text PDF Open Archive