case_images: PMC9282804_01
case_images: (a) Head magnetic resonance imaging showed a new infarction in the left insular cortex and temporal lobe. (b) Head magnetic resonance angiography (MRA). The left internal carotid artery and MCA were not clearly visible.
case_images: SNI-13-273-g001.jpg
case_images: PMC9282804_01_SNI-13-273-g001.jpg
case_images: F1
case_images: Diffusion-weighted magnetic resonance imaging (MRI) of the head showed a high-intensity zone in the left insular cortex and temporal lobe [Figure 1a]. The left ICA and MCA were not clear [Figure 1b].
case_images: (a) The left cervical computed tomography angiography (CTA), left oblique view. The left common carotid artery was totally occluded from its origin to just before the carotid bifurcation (black arrowheads). Collateral anastomosis between the left occipital artery and a small branch of the left vertebral artery was detected (red arrowheads). Severe stenosis of the left subclavian artery was also observed (black arrow). (b) Head-and-neck CTA, front view. The anterior communicating artery was well developed (arrow), although there was a small unruptured aneurysm in the artery. (c) The left cervical CTA, left lateral view. The left posterior communicating artery was hypoplastic and not visible on CTA (arrow). (d) Single-photon emission computed tomography showed a general decrease in blood flow in the left cerebral hemisphere at rest.
case_images: SNI-13-273-g002.jpg
case_images: PMC9282804_01_SNI-13-273-g002.jpg
case_images: F2
case_images: The left external carotid artery (ECA) was anastomosed with the left vertebral artery through a small branch of the occipital artery [Figure 2a]. The anterior communicating artery was well developed, although there was a small unruptured aneurysm [Figure 2b]. The left posterior communicating artery was hypoplastic [Figure 2c]. CTA also showed severe stenosis of the left subclavian artery and intermediate stenosis of the right brachiocephalic artery [Figure 2a]. Single-photon emission computed tomography (SPECT) showed a general decrease in blood flow in the left cerebral hemisphere at rest [Figure 2d].
case_images: Diffusion-weighted magnetic resonance imaging on day 16 showed the emergence of high-intensity areas on the left temporal and parietal lobes, which indicated a second stroke.
case_images: SNI-13-273-g003.jpg
case_images: PMC9282804_01_SNI-13-273-g003.jpg
case_images: F3
case_images: Diffusion-weighted MRI revealed high-intensity areas on the left temporal and parietal lobes [Figure 3].
case_images: (a) The right common carotid artery was exposed and an end-to-side anastomosis with the synthetic graft was performed. (b) The left common carotid artery was exposed, and an end-to-side anastomosis with the synthetic graft was performed. Note that a double-armed suture thread was used, and a staying suture was only made on the heel (proximal side) of the orifice. (c) Before completing the ligation of the double-armed thread, the left internal carotid artery (ICA) was temporarily released to flush the air and debris. Note that the bubble of air was flushed from the toe (distal side) of the orifice of the synthetic graft anastomosed site with retrograde blood flow from the left ICA. (d) The left external carotid artery was temporarily released to flush the air and debris through the toe of the orifice. (e) Completed anastomosis of the right common carotid artery and synthetic graft. (f) Completed anastomosis of the left common carotid artery and synthetic graft.
case_images: SNI-13-273-g004.jpg
case_images: PMC9282804_01_SNI-13-273-g004.jpg
case_images: F4
case_images: We then performed right carotid artery-synthetic graft end-to-side anastomosis with a running suture [Figure 4a]. We made a linear vascular incision with a spits scalpel, dilated the arteriotomy with an aortic puncher, and performed the synthetic graft-left CCA end-to-side anastomosis in the same way as were done for the right side [Figure 4b]. Before ligating the back and front wall suture threads, we declapmed the external and internal carotid arteries to flush the debris and air through the toe of the vascular orifice [Figures 4c and d]. After declamping, good pulsation of the synthetic graft was observed [Figures 4e and f].
case_images: (a) Postoperative computed tomography angiography, left oblique view. The crossover bypass was perfectly patent (arrowheads). (b) Postoperative single-photon emission computed tomography showed a slight increase in blood flow in the left cerebral hemisphere at rest.
case_images: SNI-13-273-g005.jpg
case_images: PMC9282804_01_SNI-13-273-g005.jpg
case_images: F5
case_images: Head-and-neck CTA showed perfect patency of the crossover bypass [Figure 5a]. The postoperative SPECT (postoperative day 14) did not show a remarkable improvement in cerebral blood flow [Figure 5b].