Carotid Endarterectomy is an operative procedure done to remove carotid atherosclerotic plaque
Contraindications of Carotid Endarterectomy
Complete occlusion – somewhat counterintuitively, once the carotid artery has been completely blocked by atherosclerotic plaque it is not possible to remove the plaque surgically without an almost certain cerebrovascular stroke occurring postoperatively.
Details of the Procedure
1. To begin carotid endarterectomy dissection is done through the platysma muscle.
2. Care must be taken to not extend the upper end of the incision too far anteriorly to avoid damaging the marginal mandibular branch of the facial nerve that runs just inferiorly to the horizontal ramus of the mandible (injury here causes lower lip paralysis).
3. The anterior border of the sternocleidomastoid muscle is exposed and retracted laterally.
4. The carotid sheath is visualized including the vagus nerve in a posterolateral position (injury to this nerve will result in vocal cord paralysis.
5. Examination in the cephalad part of the carotid endarectomy incision for the greater auricular nerve and the sensory fibers of the cervical plexus should be performed to lessen the chances of damage and the resulting sensory loss to the skin of the earlobe and angle of the mandible.
6. If exposure of the common carotid is desired, the omohyoid muscle should be divided or retracted anteriorly.
7. The hypoglossal nerve in carotid endarterectomy must be identified running horizontally across the field 1-2 cm cephalad to the bifurcation of the carotid artery (injury results in tongue deviation and dysphagia).
8. The hypoglossal nerve must be gently retracted superiorly (it is acceptable to sacrifice the ansa hypoglossal running to the strap muscles to facilitate exposure).
9. The carotid body at the bifurcation of the carotid must be identified and is usually injected with 1% lidocaine to reduce the chances of hypotension and bradycardia with manipulation.
10. The facial vein is identified and ligated and divided.
11. The carotid sheath is incised and opened both superiorly and inferiorly.
12. A Rumel tourniquet (umbilical tape passed around the veseel and then through a short length of red rubber tubing) is placed caudally (towards the feet )on the common carotid artery.
13. A vessel loop or Potts tie (00 silk tie looped twice) is placed around the superior thyroid artery.
14. A vessel loop is placed around the external carotid artery.
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