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PART 6 — MISCELLANEOUS
Figure 24-9 Grayscale image of residual plaque in proximal CCA.
nature. Pathology Box 24-1 describes the ultrasound characteristics of common pathology observed during intraoperative ultrasound examinations.
Figures 24-9 through 24-13 demonstrate an abnor- mal finding in the common carotid artery, the in- traoperative findings, and the repeat scan following revision. This is an excellent example of the benefit of direct clinical application of this policy.
INFRAINGUINAL REVASCULARIZATION
Infrainguinal revascularization can be performed for claudication or critical limb ischemia (CLI) and can be performed via percutaneous endovascular means or via open surgical bypass using either autogenous (vein) or prosthetic (Dacron or PTFE) material. Although carotid endarterectomy is a fairly standard- ized procedure, there are almost infinite variations in
Figure 24-10 Elevated-velocity CCA consistent with severe stenosis.
Figure 24-11 Dissected plaque being removed from CCA.
the performance of an infrainguinal reconstruction. Issues abound, such as assessing and obtaining ad- equate arterial inflow, choice of an appropriate con- duit for bypass depending on the level of the bypass and available autogenous material, and the choice of adequacy of an outflow target. Any or all of these is- sues can result in success or failure of the procedure and the number of steps in these often tedious oper- ations creates many opportunities for failure. Despite these significant obstacles to success, the results in terms of patency and limb salvage continue to be quite admirable.
Early in the experience with infrainguinal revascu- larization, the superiority of autologous material over prosthetic material in terms of bypass patency was demonstrated.13 Adopting an all-autologous approach has introduced using arm veins, small saphenous veins, deep veins, and even radial arteries. These “al- ternative” veins are more prone to abnormalities that
Figure 24-12 Carotid bifurcation after an endarterectomy and revision.