This case shows that the expectation of a huge increase in flow is not always met in every case. However, a significant change in the flow curve can be seen. HFUS revealed intimal flaps that were not visible on angiography. When checking the clamping sites and the intimal steps in the internal carotid artery (ICA) and external carotid artery (ECA) after the carotid endarterectomy (CEA), minor residual intimal flaps were detected but did not lead to a revision.
Patient information
- 69-year-old male
- The carotid stenosis was incidentally diagnosed during a cardiologic examination after CABG surgery.
- High-grade asymptomatic stenosis of ICA and ECA on the right side, mild/severe stenosis on the left side.
- External CT angio was not useful due to an overlay of calcifications.
- MRI angio was not performed due to claustrophobia.
Percutaneous ultrasound showed severe calcifications with peak systolic velocity at 479,7 cm/sec (Image 1).
Intraoperative completion control with HFUS and TTFM
A mini-incision in the neck was enabled by using the HFUS probe percutaneously visualizing the exact placement of the incision (Image 2). All intraoperative images were performed with HFUS. Stenosis in ICA and ECA was evaluated by using HFUS as seen in Video 3.
The TTFM probe was placed distally to the plaque, and the initial flow in the ICA was read prior to performing CEA (Image 4). Due to the bendable neck of the TTFM probe, it could be angled to fit in the mini-incision (Image 5). The surgeon performed CEA with patchplasty (Image 6), and the size of the plaque can be seen in Image 7.
HFUS completion control of the ICA was performed after CEA and a minor intimal flap <2mm was found. Since the flap did not cause turbulence that could increase the risk for subsequent thrombosis, it was left unrevised (Video 8).
HFUS completion control was also performed of the ECA. A minor intima flap at the medial wall was found but was deemed acceptable (Video 9).
TTFM completion control after CEA was performed by placing a 5 mm flow probe on the ICA, and the flow curve had a typical triphasic shape (Image 10 and 11).
Completion control with angiography was performed, and none of the intimal flaps that were detected with HFUS were visible on angio (Image 12 and 13).
