Improved Hybrid Surgery for Chronic Carotid Artery Occlusion: A Technical Note.

Abstract

An optimal surgical technique of hybrid surgery for patients with chronic total occlusion remains unclear. We report an improved hybrid strategy utilizing dual arterial sheath placement (carotid and femoral) to enhance procedural success while mitigating risks such as embolism and dissection. This procedure was collaboratively performed by vascular surgeons and neurointerventionalists. Following a carotid endarterectomy by the vascular surgery team, the neurointerventionalists managed the distal lesion via a carotid sheath, performing either balloon dilatation for an organized thrombus/collapse or direct thrombus aspiration. The vascular surgeons then removed the sheath, sutured the artery, and closed the incision. Finally, the neurointerventionalists implanted a carotid stent via a femoral artery sheath to ensure a patent arterial lumen. Two male patients in their mid-60s presented with right internal carotid artery occlusion and cerebral hypoperfusion. They underwent a collaborative surgical procedure where vascular surgeons first performed a carotid endarterectomy. Neurointerventionalists then managed the distal occlusion via a carotid sheath, employing thrombus aspiration in the first patient and balloon angioplasty in the second. Finally, stents were implanted via a femoral sheath in both cases, successfully restoring carotid artery patency without thrombus and bleeding. The improved hybrid technique combining endarterectomy with dual-sheath intervention demonstrates feasibility and safety in treating chronic carotid occlusion, though larger studies are needed to confirm its efficacy.