A case of carotid endarterectomy assisted with a three-way junction shunting tube for the internal carotid artery stenosis involving a persistent primitive hypoglossal artery

Abstract

Only several cases of internal carotid artery (ICA) stenosis involving the persistent primitive hypoglossal artery (PPHA) have been treated with carotid endarterectomy (CEA) because of its extreme rarity. CEA was performed for an 87-year-old female with severe stenosis of the right ICA-PPHA bifurcation requiring shunting from CCA to both PPHA and ICA. We initially attempted to insert two intraluminal balloon shunts into the CCA, as previously reported. However, we found this procedure technically impossible to achieve. An improvised three-way junction tube was inserted distally into PPHA and ICA and proximally into CCA, securing blood flow during CEA. Unfortunately, the patient suffered post-operative ischemic brain lesions due to the prolonged ischemic time during our initial unsuccessful shunt attempt. A three-way junction shunting tube could be an effective shunt technique during an anatomically complicated CEA.

Keywords: carotid endarterectomy; endarterectomy; internal carotid artery stenosis; persistent primitive hypoglossal artery; shunt; three-way.

Figure 1

DWI on MRI showed infarction suggestive of high signal intensity lesions at the border zones between the anterior and middle and the middle and posterior cerebral artery territories (A); CTA from a posterior view revealed that PPHA (white arrow) originated from the posterior wall of the ICA (yellow arrow); the ipsilateral vertebral artery was absent, and the contralateral VA was rudimentary (B, gray arrow); CTA from a medial view revealed that PPHA entered the cranium through the hypoglossal canal (C, white line arrow).

Figure 2

The surgical set-up is shown; the skin incision was performed along the anterior rim of the sternocleidomastoid muscle, slightly changing its direction at the right mandibular angle to the mastoid process (A); the right CCA (a), ECA(b), ICA (c, yellow dotted line), PPHA (d, white dotted line), superior thyroid artery (e) and hypoglossal nerve (f) were exposed (B); the three-way junction tube shunted the blood flow from the right CCA (black arrow) to ICA (yellow arrow) and PPHA (white arrow); the ICA (yellow dotted line) and PPHA (white dotted line) are shown (C and D).

Figure 3

SEP recordings during CEA (A, before cross-clamping of the ICA; B, during cross-clamping; C, after shunt placement and D, at the end of CEA); the N20-P25 amplitude diminished during cross-clamping (B, white arrow); it recovered after shunt placement (C, gray arrow and D, black arrow).

Figure 4

DWI in MRI demonstrated the new ischemic brain lesions on DWI 1 day after CEA in the right cerebral hemisphere cortex of the right ICA region (A); CTA demonstrated favorable patency of all arteries with an improvement of the internal carotid stenosis (B, yellow arrow: ICA, white arrow: PPHA).