Surgical Treatment of Common Carotid Artery Occlusion

Complete occlusion of the common carotid artery (CCA) has been found in 4 to 5% of patients suffering from cerebral ischemia due to atherosclerotic lesions. The classical surgical treatment of the lesion consists of retrograde thromboendar-terectomy or bypass grafting between the subclavian artery and the carotid bifurcation with the aim of restoring flow into the internal carotid artery (ICA) or revascularizing the external carotid artery (ECA) when the ICA is definitively occluded. Recent reconstructive microneurosurgical techniques offer these patients alternative or additional possibilities of cerebral revascularization. During the last 5 years, we have treated nine patients with CCA occlusion, using different techniques mainly according to the site and extent of obstruction and the anatomical conditions of the arteries. In only one patient was the ICA found to be patent: a subclavian-ICA bypass was performed. In four other patients with occlusion of the full length of the CCA (proximal lesion) and ICA occlusion, attempts at retrograde thromboendarterectomy were made and then subclavian-ECA bypass and superficial temporal-middle cerebral artery (STA-MCA) bypass were performed in two steps. In four patients with CCA obstruction limited to the carotid bifurcation area (distal lesion) and with ICA occlusion, the following techniques were used: (a) endarterectomy of the CCA and ECA and STA-MCA bypass in two steps (one case), (b) CCA-ECA bypass and STA-MCA bypass in two steps (one case), and (c) subclavian-MCA bypass (two cases). Four of nine patients were treated by contralateral ICA endarterectomy after repair of the CCA obstruction. Angiography was performed 7 to 10 days after every surgical procedure, and all arteries and grafts, originally opened, were found to be patent. No operative death occurred in the series, but one patient suffered a transient neurological deficit. During the follow-up period (average, 14 months), no ischemic episode occurred. These data suggest that a versatile surgical approach is rational for the treatment of CCA occlusion.