Let's use another video to discuss the technique of carotid endarterectomy. This is a case of a 68 year old male who presented with symptomatic left sided high grade carotid stenosis, as demonstrated on this CT angiogram. A left sided curvilinear incision was used, the edge of the sternocleidomastoid muscle was identified and the dissection along the anterior triangle of the neck continued. Following the edge of the sternocleidomastoid muscle palpation allured identification of the carotid artery. Cerebellar retractors may be situated to keep the operative field open. Continuation of the dissection, just medial to the belly of the sternocleidomastoid muscle. Allows the identification of the facial vein. There may be ligated and transected. Soft tissue dissection continues along the entire length of incision so that the exposure can be maximized. Here, you can see the carotid sheath, just medial to the belly of the external sternocleidomastoid muscle. Here's the common carotid artery, it's exposure again is maximized. I like it, the common facial vein Using two sutures. The two sutures may be passed simultaneously for advancing the efficiency of the procedure, in this video they're passed separately. Silk sutures are used to ligate the vein. Next, the vein is transected and the dissection continues along the interior wall of the common external, as well as the internal carotid arteries. Facial hooks may be placed within the sternocleidomastoid muscle. And so cervicalis is, apparent crossing the operative field. Here the dissection continues along the internal carotid artery. In this case, the artery is somewhat torturous. Here's the hypoglossal nerve. They're often branches connecting the hypoglossal nerve to the ends of cervicalis. In this case, I mobilized the ends of cervicalis nerve and move it slightly laterally. So it may be preserved. Here, you can see how it connects to the hypoglossal nerve. The internal carotid artery is circumferentially dissected. The carotid sheath is widely opened. So the surface of that vessel is clearly visible. I continue to work just above the artery. The springing action of the scissors, provides a very efficient maneuver for exposing the walls of the arteries. Here's further dissection around the circumference of the common carotid artery. The vagus nerve is located in a groove between the artery and the juggler vein. This nerve should be carefully protected. Plastic loops are used, temper clip on superior thyroid artery, palpation estimates the distal end of the plaque, a clamp is placed just distal to the plaque. An arteriotomy is created. It's often tempting to create the arteriotomy in a nonlinear fashion. Careful attention to detail, would allow the surgeon to create an arteriotomy just along the middle of the superior wall of the common, as well as the internal carotid arteries. Next, the dissection of the plaque mobilizes the plaque away from the intima of that carotid artery. I continue to dissect the plaque carefully without injuring the intima of the vessel. There's a nice plane developed between the vessel and the plaque. You can see the origin of the external carotid artery. It's really important to pay special attention during dissection of the distal end of the plaque through the internal carotid artery. Here's mobilization on the plaque, through the external carotid artery. Portion of the plaque that infiltrates into the external carotid artery is mobilized and the end of the plaque is avulsed through this portion of the artery. I spent ample amount of time dissecting the small intimal flaps that could be quite thrombogenic if not carefully handled. Heparin irrigation is used, in this case, I extend the arteriectomy to assure a very clean disconnection of the plaque along the proximal ICA. You can see a piece of plaque, the artery was further opened. I can see there was a natural plane across which the plaque was disconnected. No obvious flaps are apparent this natural line where the plaque would be disconnected is ideal. Next, the arteriotomy is closed the outside to inside and the inside to outside technique allows tacking down of the intimal flaps within their small caliber internal carotid artery. The initial closure stores from distal to the middle of the arteriectomy. And then from the proximal arteriotomy again to the middle of the arteriotomy. This vessel was relatively generous in the size of its lumen. Therefore patching was not deemed necessary. Larger bites are allowed during the closure of the common carotid artery. As similar outside to inside and inside to outside technique is used during suturing of the proximal end of the arteriotomy Two separate bites are included in their suturing technique during the beginnings of their arteriotomy closure. To, again, tack down the intimal flaps, The two sutures are extended to them midline or the middle of the arteriotomy. You can see the order of the clamp removal, the internal carotid clamp is removed first and the arteries are allowed to back bleed. Next, the common carotid artery is allowed to bleed to clear the debris. Now the final knot is placed and the order of removal of the clamps is, first common and external and finally internal. So all the debris and air can go into the external carotid artery circulation. The artery is nicely pulsatile. And the clamps are removed in the order discussed. Thank you.
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