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 ICA. 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 image after CEA
As seen in image 1, the kink on the ICA has a sharp angle and is clearly visible above the bovine patch.
An HFUS probe was used as part of the completion control after CEA to visualize a clean intima with no flow obstructions.
Intraoperative TTFM completion control
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. Hence, the kinked ICA was left untouched since both HFUS and TTFM assured the surgeon that there were no flow issues.
This case confirms that TTFM can be a valuable tool and a method to assess the hemodynamic significance of a kinked ICA.
Case Example by Dr. Neel V. Dhudshia
Medical Director of Cardiovascular and Thoracic Surgery, Saint Rose Siena Hospital, Henderson, Nevada