Commentary on “Bilateral Extracranial Carotid Artery Aneurysms Treated by Staged Surgical Repair”

Park and Kim report the case of a 35-year-old man with a bilateral aneurysm of the extracranial carotid artery treated with resection/great saphenous vein grafting in a staged fashion. The aneurysm of the right carotid artery was correctly treated first, as it was larger and contained a larger amount of intraluminal thrombus than the right one. Access to the aneurysms was gained through a curvilinear, T-shaped incision extending from the mastoid to the mid-neck. Standard pre-ternocleido-mastoid incisions can also be used and coupled to additional maneuvers to improve distal control of the internal carotid artery for aneurysms with distal extension. In this report the anatomical situation of the aneurysm required the section of the digastric muscle alone. When a potentially difficult distal exposure is anticipated at preoperative imaging and workup, nasal intubation can be considered: it allows sufficient enlargement of the distal surgical field in most cases without necessarily being associated with mandibular subluxation or resection. For aneurysms extending to the base of the skull, the distal cervical internal carotid can be controlled with an occluding Fogarty catheter passing within the graft while performing the distal graft-to-internal carotid artery anastomosis. Once the anastomosis is completed, the balloon is deflated, backbleeding is checked, and the balloon removed. As the distal anastomosis to the distal internal carotid artery is the most technically demanding it may be preferable to perform it first, with the fully mobile graft. This also allows easier tailoring of length and tension of the graft at the moment of proximal anastomosis. Truly juxtacranial or infratemporal aneurysms require surgical exposures such as those described by Fisch and Mercier, that are to be performed with the participation of otolaryngologists and require strategies that are different from those of cervical aneurysms. The choice of the graft material is an important issue. Park and Kim chose the great saphenous vein as the arterial substitute with both excellent intraoperative result and