Reconstruction of the ligated external carotid artery for embolization of cervicofacial arteriovenous malformations

Surgical Reconstruction to Allow Endovascular Access for Flow Diversion of Giant Cavernous Aneurysm: A Combined Approach

Giant cavernous aneurysms of the internal carotid artery (ICA) are challenging lesions associated with high surgical morbidity. Prior to the past several years, these were treated by surgical reconstruction, proximal ligation, or stent-assisted coiling techniques. Flow diversion has become the standard of care for these lesions, providing a high rate of obliteration with a much better safety profile. However, flow diverters rely upon a navigable vasculature and, usually, a tri-axial support system. Cases in which such access is difficult require unique approaches to combine the strengths of both surgical and endovascular therapy. A woman with a giant cavernous ICA aneurysm and an ophthalmic artery aneurysm presented for treatment, but access was challenging due to cervical ICA tortuosity and pseudoaneurysms. We elected a staged, combined approach with surgical reconstruction of the cervical ICA followed by flow diverter placement for the intracranial aneurysms. Our case features an “outside-the-box” approach that synergistically applied both microsurgical and endovascular techniques to treat a challenging pathology. Classic microsurgical techniques remain important in cases that are refractory or not amenable to endovascular therapy alone.

Anatomic evaluation of the carotid artery bifurcation in cadavers: implications for open and endovascular therapy

Knowledge of carotid bifurcation (CB), common carotid artery (CCA) and its branches and their recognition during diagnostic imaging are also important for vascular surgical procedures in the region, such as carotid endarterectomy or radical neck dissection, catheterization and aneurysms. The surgical anatomy of the carotid arteries was studied in 20 cadavers. Micrometric values of the CB and its relation with surrounding structures, measurements belonging to the external carotid artery (ECA) and internal carotid artery (ICA), and metric data, such as lower face including the greater horn, laryngeal prominence have been evaluated by making linear measures. The diameter of the CCA at the CB under 2 cm and CB diameter was measured as 8.1 +/- 2.24 mm and 12.79 +/- 2.87 mm, respectively. Evaluating data related to the ICA and the ECA in samples, the aspect was measured the ICA and the ECA in the CB discrimination point as 21.52 +/- 20.53 degrees . In the most location of the ECA origin according to the ICA has been determined as medial position in 35 specimens. The origin of the superior thyroid artery (STA) was found to be at the same level with the CB in 40% and below it in 25% specimens. This study has provided measured objective criteria for the arterial features of the neck region, which are crucial during surgery. The origins of the branches of the CCA act as key landmarks for adequate and appropriate placement of the cross-clamp on the carotid arteries.