February 03, 2016
Let's review some of the basic techniques for Carotid Endarterectomy using patch grafting. This is a 55 year-old male who represented with symptomatic right-sided high-grade carotid stenosis. You can see the extent of stenosis on the angiogram. Here's the patient positioning the turn of the head. I'll review the analysis of incision. The anterior border of the sternocleidomastoid muscle is identified. The angle of the jaw is marked straight incision is used along the anterior aspect of the muscle and incision curves posteriorly, just at the level of the angle of the jaw for further details, please refer to the text. Here's the final position for the patient after the initial exposure, proximal and distal control over all the vessels are obtained. an arteriotomy exposed the plaque one has to perform the arteriotomy along the straight line and avoid the temptation for a nonlinear arteriotomy. The arteriotomy should expose the entire length of the plaque into their ICA an additional exposure may be necessary for exposure of the distal end of the plaque. Now the proper plan is enter between the plaque and the vessel wall. In this case, I disconnected the proximal end of the plaque first using the pot scissors. This part of the operation is relatively straightforward. The tips of their scissors may be used dissectors so that the wall of the vessel is not injured. Obviously the end of the plaque entering the ECA is also circumferentially disconnected and then pulled out. The disconnection of the plaque at the level of the IC is specially important because of the caliber of the vessel is very small. There's usually a natural plane or the plaque wants to disconnect itself We're using the blunt dissection method to identify this plane. Micro scissors may be used to obviously trim this area later, here is a back bleeding to clear some of that debris and assure adequate collateral support. Here you can see using the micro scissors, the edges of the plaque were nicely trimmed. Next, I divert my attention to removal of portion of the plaque that enters the ECA so no thrombogenic surfaces present in that area. A patch graft was used in this case. The initial bites are performed, one at a time first through the patch, and then into that vessel wall separately, not a single bite is carried out in this situation so that the flaps can be tacked down over the vessel wall. As one continues with suturing, the patch larger bites of their common wall can be taken since this portion of the vessel is generous in its lumen. Another similar technique is used along the proximal portion of the plaque where the needle is first passed through the graft and then through the plaque so that the edges of the plaque can be tacked down. Here is the final stage for closure of the arteriotomy through the patch graft. Thank you.
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