October 08, 2015
Let's review some of the variations of technique for Carotid Endarterectomy. This is a 58 year old male who presented with severe left-sided carotid stenosis, and frequent TIA symptoms related to this stenosis. A left carotid endarterectomy was planned. Let's review the skin incision. I like the vertical incision, relative the horizontal incision. The incision turns posteriorly at the level of the angle of the jaw. Incision obviously follows the anterior border of the sternocleidomastoid muscle. Intraoperative EEG is used. You can see the initial exposure, the common carotid artery, the external carotid artery, the internal carotid artery and the superior thyroid artery. That was temporarily clip ligated. The distal part of the ICA within the operative field was adequately exposed, so the plaque can be handled through the arteriotomy. A temporary clip occluded the distal ICA. You can see placement of the Fogarty clamp and the vessel loop along the common carotid artery. A linear arteriotomy was completed along the anterior surface of the common and internal carotid artery. This arteriotomy extended all the way to the distal level of the plaque. The plaque was carefully dissected from the internal of the ICA. The portion of the flap that was entering the external carotid artery was also skeletonized and avulsed. All the internal flaps were carefully dissected under generous Heparin irrigation to avoid the thrombogenic surface. The lumen appears relatively clean. The outside-to-inside and the inside-to-outside technique is used along the ends of the arteriotomy so that the internal flaps can be tacked down and luminal construction can be minimized. A 9-0 suture is used in this case. The running suture continues from distal to proximal and proximal to distal, and the two sutures meet each other in the middle. More generous bites of the arterial wall can be taken along the common carotid artery. Here, you can see the tack down of the flaps along the proximal part of the arteriotomy. Here is the area where the two sutures join each other. Retrograde flow within the internal carotid artery and antegrade flow within the common carotid artery are performed to clear the debris and air before antegrade flow within the common carotid, as was as the internal carotid artery is reconstituted. The last knot is now made. Flow is reconstituted, and the Doppler microprobe confirms adequate flow within all the regional vessels. Thank you.
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