Unique findings with TTFM and HFUS during CEA in asymptomatic high-grade ICA and ECA stenosis


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 intima flaps that are not visible on angiography. When checking the clamping sites and the intima steps in the ICA and ECA after CEA, minor residual intima flaps were detected but did not lead to a revision.

Patient medical history

  • 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 as seen in image 1.


Mini-incision CEA was enabled by using Medistim High-Frequency Ultrasound probe (HFUS) see image 2. All intraoperative images were performed with HFUS. Stenosis in ICA and ECA was evaluated by using HFUS as seen in video 1.

The TTFM probe was placed distally to the plaque and the initial flow in the ICA was read prior to CEA as seen in image 3. Due to the bendable neck of the TTFM probe, it could be angled to fit in the mini-incision as seen in image 4, and Endarterectomy was performed with patch plasty as seen in images 5 and 6.

HFUS completion control of the ICA was performed after CEA and a minor intima flap <2mm was found. Since the flap did not cause turbulence that could increase the risk for subsequent thrombosis, it was left unrevised. See video 2.

HFUS completion control was also performed of the ECA. A minor intima flap at the medial wall was found but was deemed acceptable. See video 3.

TTFM completion control after CEA was performed by placing a 5mm flow probe on the ICA and the flow curve had a typical triphasic shape as seen in images 7 and 8.

Completion control with angiography was performed. None of the intima flaps that were detected with HFUS are visible. See images 9 and 10.

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