DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Severe recurrent left carotid stenosis, 4 years status post left carotid endarterectomy.
POSTOPERATIVE DIAGNOSIS:
Carotid ectasia with no evidence of hemodynamically significant stenosis.
PROCEDURES PERFORMED:
1. Thoracic arch aortogram.
2. Selective right carotid arteriography.
3. Selective left carotid arteriography.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
COMPLICATIONS:
None.
ESTIMATED BLOOD LOSS:
Minimal.
INDICATIONS FOR PROCEDURE:
The patient is a (XX)-year-old who is 4 years status post a left carotid endarterectomy performed at an outside institution. Followup carotid duplex studies revealed evidence of a critically severe, apparent recurrent carotid stenosis based on flow velocities. The patient was brought to the endovascular suite for carotid arteriography for evaluation for possible carotid angioplasty and stenting, if a hemodynamically significant recurrent stenosis was confirmed.
FINDINGS:
1. Normal thoracic arch with mild calcification at the origin of innominate, left common carotid arteries.
2. Patent vertebral arteries with no evidence of vertebral artery stenosis.
3. Mild, less than 15%, stenosis of the right carotid artery with no intracranial tandem carotid lesions.
4. Ectasia of the internal carotid artery just beyond the carotid bifurcation with no evidence of any hemodynamically significant internal carotid artery stenosis.
5. No evidence of tandem intracranial internal carotid artery lesions.
6. Normal intracranial internal carotid artery with normal bifurcation of the anterior cerebral artery and middle cerebral artery.
7. Normal M1, M2, M3 segments of the middle cerebral artery.
DESCRIPTION OF OPERATION:
The patient was brought to the endovascular suite and placed in the supine position on the angio table. The right groin was sterilely prepped and draped in the usual fashion. The right groin was anesthetized with 1% lidocaine without epinephrine for local anesthetic. A single wall puncture of the right femoral artery was performed with micropuncture technique. A 5 French sheath was placed in the right femoral artery. A 5 French pigtail catheter was advanced over a wire to the ascending aorta.
Arteriogram was obtained with 40 mL of contrast injection, rate of 20 mL/sec for 2 seconds. The pigtail catheter was exchanged for a 3DRC catheter, which was selectively advanced over the wire into the left common carotid artery, and selective left cervical and cerebral carotid arteriograms obtained with hand injection. AP and lateral and oblique views were obtained. The 3DRC catheter was then brought down to the arch and advanced over a wire into the innominate artery and then selectively into the right carotid artery. Selective cervical and cerebral right carotid angiography was performed. The 3DRC catheter was removed over the wire.
Since the lesion was in fact found to be in ectatic left internal carotid artery with no evidence of hemodynamically significant kink or stenosis associated with that ectasia, no intervention was pursued. The catheter was removed. A femoral arteriogram was obtained, which suggested the patient was a good candidate for Angio-Seal closure. The Angio-Seal was used. A pressure dressing was then applied for some mild bleeding, which quickly resolved with 5 minutes of pressure. The patient was then returned to the recovery room in excellent condition with no immediate complications apparent.
