ABSTRACT
Removal of Shunt When a shunt has been used, it will be necessary to remove it before final closure of the vessel. I do this in the following fashion. When there is approximately 1 cm of open vessel remaining, I use two small straight mosquito clamps introduced within the lumen to clamp the shunt closed with approximately 5 mm of open shunt between them. I then use straight scissors to cut the shunt in half, being certain to ensure that I do not cut the back wall in the process. The Javid or Loftus clamp is then removed from the ICA, and the distal end of the shunt is slid back and removed from the wound. A bulldog clamp is quickly reapplied to minimize backbleeding. The CCA end of the shunt is then removed by pulling it up out of the lumen at the carotid bulb. It is not necessary to significantly loosen the Rummel tourniquet to remove the shunt; doing so promotes bleeding. Once the shunt has been removed from the CCA, the DeBakey cross-clamp is immediately applied to minimize antegrade bleeding and the Rummel tourniquet is released completely. The most common error in shunt removal is to entangle the Prolene in the straight mosquito clamps used to double clamp the shunt. One must take great caution to ensure that this does not happen because Prolene tangled in the mosquito clamp will hamper removal of the cut shunt at exactly the worst possible time.
