ABSTRACT
When the shunt lumen has been evacuated, suction is used to completely empty the ICA of blood or residual debris. The assistant then removes the bulldog clamp allowing the ICA to backbleed. At the same time, the shunt is advanced up the backbleeding ICA in the gentlest possible fashion; when it has been initially placed, the DeBakey forceps can be removed allowing the shunt to bleed forward as well. This process of antegrade bleeding in the shunt blows open the ICA to some extent and prevents the shunt from abutting against the vessel wall. If there is the least bit of resistance to passage of the shunt, I stop, remove it, and try again, but it usually slides up quite freely without a problem. The shunt is advanced until the black dot appears in the center of the wound at the region of the carotid bulb. This black dot has 7 1/2 cm of shunt on either side of it and ensures that the shunt is properly placed. It serves as a marker throughout the operative procedure to prevent unnoticed cephalad migration of the shunt with possible dislodgment from the CCA.
