Upon identifying the carotid bifurcation, the ICA, external carotid artery (ECA), and CCA were localized and secured with colored rubber bands for reference. Distal control was then achieved, followed by proximal dissection of the carotid artery below the brachiocephalic vein. A complete transection of the carotid artery, approximately 5 cm in length, was found in the proximal third. After obtaining proximal and distal control, the clamp was released distally, and a thrombectomy was performed with a 5 mm resection, restoring adequate retrograde flow. The same technique was applied proximally, and the artery was flushed with 0.9% saline solution and heparin.

Reconstruction was performed using a 6 mm diameter synthetic vascular prosthesis made of expanded polytetrafluoroethylene (ePTFE) (Fig. 2). The first anastomosis was completed proximally using an end-to-end technique with a 90° cut, secured with 6-0 non-absorbable polypropylene (PROLENE) sutures, achieving adequate flow. For the distal anastomosis, a 45° cut was made to optimize the anastomotic diameter. Inverted sutures were used posteriorly with an endoluminal technique to limit graft movement, while a standard continuous technique was applied anteriorly, both using 6-0 PROLENE sutures. During the surgical procedure, the anesthesia team administed 5,000 UI intravenous to prevent thrombosis, and 24 hours after surgery we started a 100 mg aspirin PO, for 6 months. Once completing the anastomoses, all sites were irrigated with heparinized solution, and distal flow and pulsations were confirmed in both the ICA and ECA.

The platysma muscle was closed with 2-0 absorbable polyglactin sutures, and the skin was closed with 3-0 nylon sutures. A soft drain was placed, and the estimated blood loss by the end of the procedure was 100 ml.

One hour after the surgery, sedation was discontinued, and the patient demonstrated significant clinical improvement. Strength in all four limbs was rated 5/5, and the patient was responsive to commands, though a speech evaluation was not performed due to the tracheostomy. Twenty-four hours postoperatively, a CT angiography confirmed adequate patency of the reconstructed (CCA). A carotid Doppler study indicated a velocity of 137 cm/s at the graft site (Fig. 3). The drainage was removed 48 hours after the surgery, and the patient was discharged from the ICU 72 hours post-procedure.

The patient in this case presented with a neurological deficit predominantly affecting the MCA territory, along with a small stroke in the watershed area. This suggests that collateral flow was maintaining the patient in a penumbra state, with the stroke attributed to a hypoperfusion event during the initial surgery, likely caused by bleeding [19].

Ideally, perfusion tests (CT, magnetic resonance imaging (MRI), positron emission tomography (PET)) with and without Diamox or CO2 challenge would be used to assess the cerebral blood flow, volume, time to peak (TTP), and mean transit time (TTM) both at rest and during vasodilatory challenge, to evaluate the patient’s “hemodynamic reserve.” [18] However, in this case, perfusion studies were unavailable. Considering the increased risk of another stroke in the event of acute hypotension or hypoperfusion, along with long-term risk of vascular dementia due to chronic hypoperfusion, the decision was made to perform revascularization of the entire carotid territory with a bypass graft [3,15].

Further scenarios could also be considered, depending on the viability of the carotid ends [5], the different surgical strategies analyzed by the senior neurosurgeon by his experience are explained in the Table 1.

The CCA is typically repaired with a 6 to 8 mm ePTFE graft, which has demonstrated better outcomes when compared to a saphenous vein graft (SVG), with long-term patency rates of 88.9% and 66.7% respectively [2]. Also, it has demonstrated better tolerance and adaptability to the high flow and low resistance in the carotid bypass. Occasionally, the CCA is large enough to accommodate a 10 mm graft. In cases of contamination, a reversed SVG can be used as an alternative [6]. However, this method has the drawback of being prone to generate aneurysm or stenosis due to inherent characteristics of the vessel wall, including the presence of valves [4,7].

It is important to note that contrast studies only assess the patency of the graft and anastomoses, but do not provide detailed information about the flow through the graft itself. Therefore, both a CT angiogram and a Doppler study were performed. Using Doppler velocity (137 cm/s) and the graft diameter (6 mm), the flow rate was estimated using the formula Q=V×A, resulting in a calculated flow of 2,324 ml/minute through the graft. Although the normal carotid velocity is typically below 125 cm/s, it is expected that the carotid body and cerebral vasoreactivity will regulate this in the coming weeks [1,18].

The prevention periprocedural strokes and postprocedural are as important as the surgical technique, trans procedural intravenous administration of 5,000 heparin has demonstrated to prevent thrombosis of the bypass, and at least 6 months of aspiring after the procedure same as until the wall shear stress achieve self-regulation [9,10].

ICA injuries should be repaired in the same surgical procedure using a reverse SVG, a patch, or synthetic grafts. However, if the patient is hemodynamically unstable, addressing this instability should be the priority in the ICU. Carotid repair must then be completed within 6 to 24 hours of any neurological deficit or signs of ischemia to reestablish cerebral perfusion, as was done in the case presented [14].