ABSTRACT
I have emphasized that the shunt needs to be inserted with the gentlest of techniques in the ICA. As described previously, I never force a shunt if it does not slide readily up in the ICA because the advancing end of the shunt may theoretically roughen or damage the intimal high in the ICA beyond the area of the arteriotomy, leading to dissection of the ICA with consequent thrombosis and embolic phenomena and devastating neurologic consequences for the patient. This potential damage is illustrated in this drawing in which forceful insertion of the shunt is shown to raise an intimal flap. Of course, this is an extremely uncommon phenomenon. In the vast majority of my cases, the shunt is placed with absolutely no difficulty up into the ICA so long as the ICA is allowed to backbleed during the process and the shunt is held open so that antegrade flow blows the vessel walls apart and out of harm’s way.
