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Carotid Endarterectomy: Principles of Patch Grafting

April 29, 2016


This video reviews the details for carotid endarterectomy and patch grafting. This is a 69 year old male with right-sided high-grade carotid artery stenosis. Here's the incision. The vertical limb of incision is parallel to the interior edge of the sternocleidomastoid muscle. This incision curves posteriorly at the level of angle of the jaw. You can see the turn of the head just slightly contra laterally. This patient had a high-grade carotid stenosis, as you can see, a significant one with evidence of calcification within the plaque. Let's go ahead and review the principles from the very beginning. I use a knife blade, 10 blade knife to complete the incision, and then use another blade to continue subcutaneous dissection initially all the way to the anterior belly of this sternocleidomastoid muscle. I believe this method of dissection using the blade has a significant efficiency to dissection of the superficial layers. I look for the anterior belly of the sternocleidomastoid muscle. Fish hooks are used immediately to retract the subcutaneous layers. Metzenbaum scissors are used next to further define the anterior belly of the sternocleidomastoid muscle. Palpation guides the surgeon regarding the location of the carotid sheath. You can see the carotid sheath there, the jugular vein. I continue blunt dissection. The jugular vein is mobilized laterally. The common facial venous isolated and two sutures the vain. The vain is transected and a dissection parallel to the carotid sheath continues. Again, the jugular vein is apparent here. Soft tissue dissection continues more superiorly. Here's the carotid sheath. It's carefully opened. I keep the sheath intact, and cut the sheath right over the artery, so that the sheath itself can be used to be placed under the fish hooks, so that the carotid is lifted out of its groove. This is a very important maneuver. Here you can see how using the sheath as a handle to elevate the carotid artery can facilitate shortening the work in distance of the surgeon. Common carotid artery is immediately apparent. I continue further opening of the deeper layers of the carotid sheath. Circumferential dissection of the common carotid artery continues. Vessel loops are used for proximal control. I palpate the plaque and make sure I have enough of the internal carotid artery exposed. I surely don't wanna be struggling in terms of exposing the age of the plaque around the superior extent of our exposure. Here's the proximal control over the external carotid artery. Temporary clip is placed across the superior thyroid artery. Heparin is injected. Either a temporary clip or a special clamp can be used on the internal carotid artery. After the regional is secured, arteriotomy is completed and in a straight line. You can see this plaque is quite calcified and very irregular. A proper dissection planes against the wall of the artery are recognized. The wall of the artery is carefully handled. You can see the calcification can embed itself within the wall of the artery, making the dissection quite difficult. The arteriotomy was extended more proximally. Pots scissors are used to cut the proximal end of the plaque. You can see the scissor is used as a dissector, so that the back wall of the artery is not injured. I pay a special attention for transection of the plaque within the internal carotid artery since the caliber of the artery is small and any significant flaps can lead to very significant thrombogenic surface. Now, the plaque is being removed. It is through its segment within the external carotid artery after a portion of the plaque within the external carotid artery is exposed. The flaps are clearly dissected, so no free floating edges are apparent. Heparin solution is used to identify the free flaps. Here you can see use of micro scissors to cut the flap within the internal carotid artery at a natural plane. You can see the final result. There's no obvious flap upon irrigation of the area. Appears relatively clean. The origin of external carotid artery is also cleaned out further. I'm pretty satisfied with the result of plaque removal. In this patient, I performed a patch angioplasty. The initial sutures are placed in two passes, first through the graft and then through the artery. The part of the plaque that is within the internal carotid artery can be tacked down, preventing any risk of postoperative thrombosis. As I move toward the common carotid artery, larger bites can be taken since the caliber of the artery is much larger in this area. You can see the motion in terms of grabbing the wall of the artery. Similar maneuver is performed within the proximal end of the arteriotomy where two passes are required to make sure that the edges of the plaque removal are tacked down. Now, the patch is cut in oblique fashion, tailored for the area of the arteriotomy. Again, the place where the plaque was cut and trimmed, those flaps are tacked down. I go in and continue suturing, and completing the closure to the midsection of the carotid artery, and then return to the most distal part of the closure where I use similar technique for tacking down the flaps within the internal carotid artery. Ample amount of heparin irrigation is used. Here you can see the lumen of the vessel is being well irrigated before the funnel sutures are implanted. Back-bleeding is necessary through the internal and common carotid arteries to clear the debris and air. The final knot is completed. Some bleeding was encountered and additional suture was placed at this area of the patch closure. Here's the final result. The closure is complete in standard fashion. Here's the approximated. A drain is placed over the carotid artery most often, and their stuff layers are closed in the anatomical layers. Thank you.

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