The patient a Yemeni citizen came to the clinic 19-July-2004 with history of CVA 3 months ago with right sided hemiparesis and hypalgesia. He is a diabetic and hypertensive for 3 years under treatment. MRI of the brain with MRA showed recent infarction at the left cerebral hemisphere.

On examination: The patient is with right sided hemiparesis and hemihypalgesia and total aphasia, not responding to verbal communication, but stable vital signs.

The patient sent for investigations and MRA of the neck performed 22-July-2004 showed severe stenosis of the left CCA and ICA exceeding 90%. There is infarction at the left parieto-temporal lobes.

Exposure of the left CCA and ICA, ECA and superior thyroid arteries and clamping applied to all of them. It was necessary to legate and bisect the facial vein to have good exposure to the field. Check for back flow from the ICA was sufficient through cross circulation, for what it was unnecessary to use bypass shunt. The CCA and ICA were opened and the huge atheroma was resected in 2 huge pieces and meticulous cleaning of the debris were removed and washed by saline and Papaverine. Using 5 zero nylon water tight closure of the arterial opening. Clamps were removed in the following manner: First the CCA was released to see of there is still leak from the stitched wound, the the ECA and posterior thyroid artery. After application of Papaverine, the ICA was opened. The flow is smooth and no leak from the stitched wall of the CCA and ICA. The arteries are pulsating good and strict hemostasis.

Smooth postoperative recovery and the patient was sent to the ICU for 2 days observation.

The patient came to the clinic 10-August-2004 with clean wound with the same neurologic deficit. He was advised to continue physiotherapy and given medication.

Endarthrectomy of the severely stenosed ICA has advantage, even if the affected side will not recover. at least will prevent further deterioration in case of progressing atheroma in the contralateral side.