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Common Carotid Artery Thrombosis with Recurrent Cerebral Emboli, Treated with Ligation
JACQUELENN STUHLDREHER, Roberto Calderon, Shahab Toursavadkohi, THOMAS MONAHAN.
UNIVERSITY OF MARYLAND MEDICAL CENTER, BALTIMORE, MD, USA.

The patient is a 58 year-old man who presented with recurrent left-sided amaurosis fugax. Retinal examination demonstrated hemi-occlusion of the left retinal artery. Computed tomographic angiography of the neck demonstrated minimal atherosclerotic disease of the aorta and arch vessels, with complete occlusion of the left common carotid artery (CCA) (Figure 1, arrow indicates occluded CCA). The left external carotid artery (ECA) and the internal carotid artery (ICA) were both patent. Magnetic resonance imaging of the brain demonstrated a persistent fetal takeoff of the posterior cerebral artery from the ICA, with subacute infarcts present in the left middle and posterior cerebral artery territories. Transthoracic echocardiogram did not demonstrate cardiac thrombus or valvular vegetations.
The patient was diagnosed with left common carotid artery thrombotic occlusion, with associated amaurosis fugax and cerebral infarction. Continued embolic showering was a concern, due persistent antegrade ICA flow via the ECA. He was taken to the operating room for ligation of left CCA. Upon transecting the CCA, subacute and acute thrombus was encountered. There was a “tail” of thrombus extending from the CCA into the ICA, and the underlying intima was normal (Figure 2, the arrow is the tail of thrombus extending into the ICA). The CCA was oversewn. The bifurcation was oversewn, careful to preserve the lumens of the external and internal carotid arteries. Intraoperative Doppler evaluation revealed low-resistance signals in the ECA and ICA.
Postoperatively the patient did well, with no further visual changes. He is undergoing evaluation for a hypercogulable state, and will be maintained on therapeutic anticoagulation.
Thrombosis of the common carotid artery, without evidence of concurrent atherosclerosis, is rare. Treatment options vary, depending on the clinical manifestations of the patient. This patient exhibited findings similar in pathophysiology to carotid stump syndrome, with ipsilateral cerebral infarction and ophthalmic artery occlusion. This case demonstrates unique management of an unusual carotid artery lesion, with a favorable postoperative outcome.


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