Shunt-related internal carotid artery dissection during carotid endarterectomy: illustrative cases.

backgroundIntraoperative shunt use during carotid endarterectomy (CEA), although critical for cerebral protection, may cause internal carotid artery (ICA) dissection in approximately 0.5% of cases. Shunt-induced dissections represent a distinct pathophysiological mechanism, differing from surgical technique-related dissection, and typically occur distal to the arteriotomy site due to trauma from shunt tips or balloon inflation. OBSERVATIONS: The authors present 2 cases of ICA dissection occurring during CEA with shunt use, both successfully managed with emergency endovascular stent insertion. In both case, complete resolution was achieved, with modified Rankin Scale scores of 0. Case 1 involved a 70-year-old male with 95% right carotid stenosis who developed dissection extending 6 cm distal to the arteriotomy. Dual-stent carotid artery stent placement resulted in complete resolution. Case 2 involved an 80-year-old female who developed extensive 55-mm left internal carotid dissection, immediately treated with overlapping dual-stent placement. A literature review of 13 cases demonstrated favorable outcomes with recent endovascular management approaches. LESSONS: Shunt-related dissection is a preventable complication requiring specific technical precautions, including ensuring symmetric balloon expansion, using a gentle insertion technique, and minimizing longitudinal movement. When dissection occurs, immediate endovascular stent placement may provide superior outcomes compared with conservative management, effectively preventing thromboembolic complications while achieving excellent functional recovery. https://thejns.org/doi/10.3171/CASE25697.