Carotid artery occlusion and internal carotid artery occlusion has attracted a great deal of attention, while common carotid artery occlusion (CCAO) is often ignored. Since external carotid artery occlusion generally does not cause patients’ symptoms, so the CCAO is usually confused with the internal carotid artery occlusion. In fact, CCAO and internal carotid artery occlusion are completely different in incidence, clinical manifestation and therapeutic method. The incidence of chronic internal carotid artery occlusion is about 6/100,000. In the internal carotid artery occlusion, if collateral circulation compensation is good, the patients may have no symptoms; if the collateral circulation compensation is poor, the patients may suffer from transient ischemic attack, or mild or severe ischemic stroke.
Besides the bypass, intravascular intervention has also been used in the treatment of internal carotid artery occlusion, but it may bring a certain risk. The CCAO incidence is low, accounting for about 0.5% of the patients with ischemic stroke found by Doppler ultrasound, and only 2–4% of the patients with symptomatic cerebral blood supply deficiency confirmed by angiography. Most patients with CCAO (94.5%) have symptoms mainly including hemispheric blood supply deficiency, hemispheric stroke, amaurosis, etc.
The patients with CCAO that received surgical treatment in our hospital between 2011 and 2018 were retrospectively collected in this study. The inclusion criteria were: (I) CCAO confirmed by Doppler ultrasound, CT and digital subtraction angiography (DSA) as well as caused by atherosclerosis; (II) having symptoms of ischemic stroke or cerebral insufficiency caused by ipsilateral CCAO; and (III) decreased computed tomography perfusion (CTP) in the CCAO blood supply area.
Carotid-carotid crossover bypass - After exposing the distal end and bifurcation of the affected common carotid artery and the middle part of the contralateral, retropharyngeal space was separated by fingers, and then a synthetic vascular graft passed through it. Systemic heparinization the end to side anastomosis between the synthetic vascular graft and the distal end of the affected CCA was first performed.
Ring-stripping hybrid operation - Aortic arch angiography was performed by femoral artery puncture to determine the initial part of the occlusive CCA, and then an 8F guide catheter was placed near the initial part. The affected CCA was exposed from its stump to middle part followed by systemic heparin.
From 2011 to 2018, 6 cases with Rile’s type 1A CCAO received surgery in our department. Of the 6 cases, 4 were male and 2 females, with a mean age of 62.7 years. Their symptoms included amaurosis, somnolence, transient ischemic attack (TIA) and limb weakness. In the 6 cases, 4 had hypertension, 3 diabetes mellitus, one coronary heart disease and 4 a history of smoking. All the 6 cases had the left CCAO combined with decreased CTP in the left internal carotid artery blood supply area.
CCAO incidence is low and there are a few reports about CCAO. There are no guidelines and consistent opinions on its treatment. Its natural history, surgical indications and best surgical scheme are not clear. We explored the surgical treatment for CCAO based on reviewing some studies.
Advantages of ring-stripping hybrid operation
Apparently, opening occlusive CCA in situ is the best for restoring normal physiological channel. However, it is difficult and dangerous only to use catheter and guide wire to open occlusive CCA, because catheter and guide wire cannot easily pass through large calcified plaques, and exfoliated plaques are likely to cause far-end infarction. Hybrid operation overcomes the above shortcomings, greatly increasing the probability of opening occlusive CCA and reducing the incidence of far-end infarction.
The advantages of ring-stripping are as follows: (I) only blocking CCA stump and retaining internal carotid artery blood flow without reduction of intracranial blood supply during operation; (II) removing most of the plaques by ring-striper, and reducing the chance of restenosis; (III) reducing the chance of far-end infarction due to retrogradely opening occlusive CCA and blocking CCA stump; (IV) opening most of the occlusive segments under direct vision, only small segments (3–4 cm) under fluoroscopy; and (V) after retrogradely opening, stent placement to resolve residual stenosis if necessary. In this study, the mean operation time and mean hospital stay were markedly shorter in the 2 cases receiving ring-stripping hybrid operation
In this study, 6 cases with Rile’s type 1A CCAO including 4 receiving carotid-carotid crossover bypass and 2 receiving ring-stripping hybrid operation, all obtained better therapeutic effects. We believe that (I) CCAO surgical indications include Rile’s type 1A, CCAO-related symptoms and decreased CTP; (II) carotid-carotid crossover bypass is a good choice in bypass schemes because of easy operation and good long-term patency; and (III) ring-stripping hybrid operation may be an ideal surgical scheme for Rile’s type 1A CCAO.