Commentary on “Bilateral Extracranial Carotid Artery Aneurysms Treated by Staged Surgical Repair”

摘要

Park and Kim1 report the case of a 35-year-old man with abilateral aneurysm of the extracranial carotid artery treatedwith resection/great saphenous vein grafting in a stagedfashion. The aneurysm of the right carotid artery wascorrectly treated first, as it was larger and contained a largeramount of intraluminal thrombus than the right one. Accessto the aneurysms was gained through a curvilinear, T-shaped incision extending from the mastoid to the mid-neck.Standard pre-ternocleido-mastoid incisions can also beused and coupled to additional maneuvers to improve distalcontrol of the internal carotid artery for aneurysms withdistal extension. In this report the anatomical situation ofthe aneurysm required the section of the digastric musclealone. When a potentially difficult distal exposure is anticipated at preoperative imaging and workup, nasal intubation can be considered: it allows sufficient enlargement ofthe distal surgical field in most cases without necessarilybeing associated with mandibular subluxation or resection.For aneurysms extending to the base of the skull, the distalcervical internal carotid can be controlled with an occludingFogarty catheter passing within the graft while performingthe distal graft-to-internal carotid artery anastomosis. Oncethe anastomosis is completed, the balloon is deflated, backbleeding is checked, and the balloon removed. As the distalanastomosis to the distal internal carotid artery is the mosttechnically demanding it may be preferable to perform itfirst, with the fully mobile graft. This also allows easiertailoring of length and tension of the graft at the moment ofproximal anastomosis. Truly juxtacranial or infratemporalaneurysms require surgical exposures such as thosedescribed by Fisch and Mercier,2,3 that are to be performedwith the participation of otolaryngologists and requirestrategies that are different from those of cervicalaneurysms.