Bailout Percutaneous External Shunt to Restore Carotid Flow in a Patient With Acute Type A Aortic Dissection and Carotid Occlusion

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Abstract

Purpose:

To report the use of an external common femoral to carotid artery shunt in the setting of acute type A aortic dissection associated with carotid occlusion and stroke.

Technique:

The procedure is illustrated in a 52-year-old man who presented with a type A dissection extending into the innominate trunk, with associated occlusion of the right common carotid artery (CCA). Angiography showed no collateral circulation to the right cerebral hemisphere. To re-establish brain perfusion in this setting, a percutaneous external shunt was installed from the common femoral artery to the right CCA. The 5-F femoral sheath used during diagnostic angiography was replaced by an 8-F femoral introducer securely fixed to the skin with silk sutures. Ultrasound-guided percutaneous CCA access was obtained using an 18-G needle and a 6-F introducer, also sutured to the skin. The ICA and intracranial branches showed no evidence of thrombosis at this level. A plastic tube was used to connect the femoral and carotid sheath side arms to restore ICA flow. Transcranial Doppler showed normal flow at the right middle cerebral artery after shunt placement. The patient was immediately transferred to the operating room for aortic surgery, during which an intrapericardially ruptured aorta was found. The ascending aorta and proximal arch were replaced under cardiopulmonary bypass and circulatory arrest, but the patient died during the procedure due to uncontrolled bleeding.

Conclusion:

A temporary percutaneous external femoral-carotid shunt can restore blood flow to the brain whenever the carotid artery is occluded by the dissection flap and adequate collateral flow is absent.

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