Plate 160

If intraluminal shunting is elected with a Pruitt-Inahara shunt it needs to be flushed and prepped ahead of time. Heparinized saline is flushed through the irrigating port and hemostats are placed on the proximal and distal limbs of the shunt directly adjacent to the irrigating port. The distal end is inserted first and the balloon is gently inflated to seal off back bleeding around the shunt (Figure 7). The distal hemostat is opened and the distal limb aspirated back through the irrigating limb to remove all air. The hemostat is reapplied. The proximal end of the shunt is then inserted into the common carotid artery and the balloon gently inflated to prevent any antegrade flow around the shunt (Figures 8 and 9). Overinflation is to be avoided to prevent tearing of the intima or prolapsing of the balloon over the end of the shunt and occluding flow. The proximal hemostat is removed and the limb aspirated through the irrigating port to remove any air or debris. The aspirating process should be repeated one more time and the hemostats removed to establish flow through the shunt. The shunt is checked with the Doppler probe to check for flow and the endarterectomy is them commenced. With experience and planning placement of such a shunt should consume no more than 60 to 90 seconds.

Endarterectomy then is begun in the distal common carotid artery, using a Freer elevator, blunt spatula, or a mosquito hemostat. The appropriate endarterectomy plane usually is identified easily in the mid to outer media, leaving a smooth, glistening reddish-brown arterial wall behind (Figure 10).

This dissection is continued quite carefully in an attempt to elevate the plaque circumferentially. A blunt-tipped right-angle clamp is often valuable (Figure 11). The plaque then is divided proximally with the Potts scissors to facilitate exposure. The endarterectomy then proceeds distally in a meticulous fashion, care being taken to maintain a single endarterectomy plane. The most important aspect of the procedure is the delicate feathering of the endarterectomy at the distal boundary of the atheromatous plaque. No flap or shelf can be tolerated, since a technical fault will result in dissection after restoration of prograde flow with subsequent thrombosis and probable neurologic catastrophe. Plaque is removed similarly from the external carotid orifice allowing removal of the specimen (Figure 12). All residual debris then is removed carefully with forceps in a circumferential direction. A Kitner sponge also may be helpful in clearing the field of debris. Heparinized saline is used to irrigate the field, allowing free removal of clot. Forceful irrigation distally may reveal elevation of a distal flap that may require attention or tacking sutures (Figure 13).

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