Kinked Internal Carotid Artery during CEA: Revision avoided due to TTFM

This case shows the benefit of using Transit Time Flow Measurement (TTFM) in addition to High-Frequency Ultrasound (HFUS) after CEA when dealing with a kinked Internal Carotid Artery (ICA).

Case story

Finding kinks like these before performing CEA are not uncommon in elderly people. The surgeon decided not to repair the kink since it could result in more kinks upstream causing further problems. Nor did he shorten the artery since it might increase the risk of creating an unwanted flap. When he measured the flow with TTFM after CEA, he found it satisfactory hence avoiding further revision.

Intraoperative completion control with TTFM and HFUS

As seen in Image 1, the kink on the ICA has a sharp angle and is clearly visible above the bovine patch. The flow probe was placed on the ICA distally to the patch and TTFM indicated adequate flow volume with a low PI and a steady, repetitive flow curve as seen in Image 2.

The high-frequency imaging probe was used as part of the completion control after CEA to visualize a clean intima with no flow obstructions as seen in Videos 3-5.

  • Video 3 shows the patched common carotid.
  • Video 4 shows the patched internal carotid.
  • Video 5 shows a cross-sectional view through the kink with no narrowing of the lumen.
  • Image 6 shows the whole imaging sequence with the ultrasound images overlapping the photo in Image 1.

TTFM and HFUS assured the surgeon that there were no flow issues, hence, the kinked ICA was left untouched. This case confirms that TTFM can be a valuable tool and a method to assess the hemodynamic significance of a kinked ICA in addition to imaging the carotids after CEA.

Case attachments

Click images below to view.
Capture of a CEA procedure

Photo of kink on the ICA above the patch

Photo of kink on the ICA above the patch

CEA TTFM reading image

TTFM after CEA showing adequate flow

TTFM after CEA showing adequate flow

HFUS showing patched common carotid

HFUS showing patched common carotid

HFUS showing patched internal carotid

HFUS showing patched internal carotid

HFUS showing cross-sectional view through the kink with narrowing of the lumen

HFUS showing cross-sectional view through the kink with narrowing of the lumen

Kink on the internal carotid artery above the patch

HFUS imaging sequence overlapping photo in Image 1

HFUS imaging sequence overlapping photo in Image 1

Capture of a CEA procedure
Image 1

Image 1

CEA TTFM reading image
Image 2

Image 2

Video 3

Video 3

Video 4

Video 4

Video 5

Video 5

Kink on the internal carotid artery above the patch
Image 6

Image 6

Reference

Case example by Dr. Neel V. Dhudshia, Medical Director of Cardiovascular and Thoracic Surgery, Saint Rose Siena Hospital, Henderson, Nevada.

Technology used

Medistim MiraQ™ Ultimate System with TTFM Probes and L15 High-Frequency Ultrasound Probe.

Capture of a CEA procedure

Photo of kink on the ICA above the patch

Photo of kink on the ICA above the patch

CEA TTFM reading image

TTFM after CEA showing adequate flow

TTFM after CEA showing adequate flow

HFUS showing patched common carotid

HFUS showing patched common carotid

HFUS showing patched internal carotid

HFUS showing patched internal carotid

HFUS showing cross-sectional view through the kink with narrowing of the lumen

HFUS showing cross-sectional view through the kink with narrowing of the lumen

Kink on the internal carotid artery above the patch

HFUS imaging sequence overlapping photo in Image 1

HFUS imaging sequence overlapping photo in Image 1