Carotid Endarterectomy Requiring Intra-Arterial Shunting-A Technical Overview: 2-Dimensional Operative Video

Carotid endarterectomy (CEA) is a common procedure for treatment of cervical internal carotid artery (ICA) atherosclerosis. ICA stenosis is a risk factor for embolic cerebral infarction, and randomized trials have confirmed CEA as the safest, most effective treatment for most patients with this disease. Although most CEA patients tolerate the ICA cross clamping required for open endarterectomy, some patients with poor collateralization across the circle of Willis experience early ischemic changes and require an intravascular shunt to ensure adequate perfusion of the brain during CEA and arterial closure. If electroencephalography changes are noted after ICA cross-clamping, the steps for intravascular shunt placement and removal are as follows: (1) Rapidly complete CEA under cross-clamping. (2) Remove the DeBakey clamp from the common carotid artery (CCA), insert the proximal shunt catheter into the CCA, and secure the shunt with a Rumel tourniquet. (3) Remove the aneurysm clip from the ICA, insert the distal shunt catheter into the ICA, and secure the shunt with a second Rumel tourniquet. (4) Perform arteriotomy repair with 6-0 Prolene in a simple running fashion. (5) Remove the ICA Rumel, remove the distal shunt from the ICA, and replace the aneurysm clip on the ICA. (6) Remove the CCA Rumel, remove the proximal shunt from the CCA, and replace the DeBakey clamp on the CCA. (7) Perform intravascular irrigation with heparinized saline, final closure of the suture line, and removal of the ECA aneurysm clip, CCA DeBakey clamp, and ICA aneurysm clip. The patient consented to the procedure.