BACKGROUND: Perioperative symptomatic carotid artery occlusion after carotid endarterectomy is a rare complication. In this study, we present a case of symptomatic acute carotid artery occlusion that occurred after carotid endarterectomy in a patient with coexistent subclavian artery steal phenomenon, which was successfully treated with subclavian artery stenting. CASE PRESENTATION: A 57-year-old East Asian female presented with stenosis in the left common carotid artery and left subclavian artery along with subclavian steal. The proximal segment of the left anterior cerebral artery was hypoplastic, and the posterior communicating arteries on both sides were well-developed. Left internal carotid artery stenosis progressed during the follow-up examination; therefore, left carotid endarterectomy was performed. On the following day, symptoms of cerebral perfusion deficiency appeared due to occlusion of the left carotid artery. The stenotic origin of the left common carotid artery and the suspected massive thrombus in the left carotid artery posed challenges to carotid revascularization. Therefore, left subclavian artery stenting for the subclavian steal phenomenon was determined to be the best option for restoring cerebral blood flow to the whole brain. Her symptoms improved after the procedure, and the postprocedural workup revealed improved cerebral blood flow. CONCLUSION: Subclavian artery stenting is safe and may be helpful in patients with cerebral perfusion deficiency caused by intractable acute carotid occlusion coexisting with the subclavian steal phenomenon. Revascularization of asymptomatic subclavian artery stenosis is generally not recommended. However, cerebral circulatory insufficiency as a comorbidity may be worth considering.
Carotid Stenosis , Cerebrovascular Circulation , Endarterectomy, Carotid , Stents , Subclavian Steal Syndrome , Humans , Female , Subclavian Steal Syndrome/surgery , Middle Aged , Carotid Stenosis/surgery , Treatment Outcome , Subclavian Artery/surgery , Postoperative Complications/surgery , Postoperative Complications/etiology
Carotid webs cause ischemic stroke in young people and are associated with a high rate of stroke recurrence. Histopathological examination is crucial for clarifying the pathogenesis and mechanisms underlying the occurrence of carotid webs, although the mechanisms generally remain unclear. Here, we report a case of a symptomatic carotid web in a woman in her 50s who had a medical history of two ischemic strokes. She was diagnosed with a right carotid web and underwent carotid endarterectomy 18 days after the second stroke. Histopathological examination clearly revealed several phases of intimal hyperplasia. Furthermore, a thrombus attached to the carotid web showed invasion by fibroblasts and capillaries, and organization had begun. We presume that after the appearance of the carotid web, the thrombus formed by stagnant flow and became organized, causing the carotid web to grow and change in shape.
OBJECTIVE: In aneurysm clipping, the use of an endoscope improves the visualization of the anatomic structures around the aneurysm, allowing for improved dissection and clipping techniques. Furthermore, it makes the surgery less invasive. The disadvantage of using the endoscope and microscope together is that the surgeon must move the line of sight significantly between viewing the operative field through the eyepiece of the microscope and viewing the endoscope monitor. This disadvantage makes it difficult for the surgeon to safely insert the endoscope in the optimal position. This study presents a new method for observing the surgical field with a picture-in-picture system using both an endoscope and an exoscope that can overcome the disadvantage of multiscope surgery. METHODS: The endoscope was used when the anatomic structures around the aneurysm could not be observed with the exoscope only. An image from the endoscopic monitor was inserted into the exoscopic monitor. The surgeon inserted the endoscope in the optimal position while viewing the endoscope monitor and ensured that the structures in the path of the endoscope were not damaged while they viewed the exoscope monitor. RESULTS: Three patients underwent aneurysm clipping. The use of an endoscope made the procedure less invasive, and the surgeon was able to safely insert the endoscope in the optimal position. Only slight movement of the line of sight was required to view the 2 monitors. CONCLUSIONS: The endoscope and exoscope multiscope picture-in-picture system can facilitate safer aneurysm clipping compared with combined microscopic and endoscopic surgery.
