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

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.

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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.

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