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INDICATIONS

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The role of carotid endarterectomy is the prevention of strokes in patients with systemic disease of the vascular system. The indications for the procedure are varied, but the chief indication is transient ischemia. When the symptoms of cerebral ischemia are transient, intermittent, and self-resolving, the results of surgical correction of the area of carotid stenosis are excellent. The operation may be considered in some patients who have recovered from old strokes who develop new symptoms. Mild intracranial disease with severe proximal disease is another indication for carotid endarterectomy. The two principal indications are asymptomatic high-grade stenosis and transient ischemia.

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Duplex ultrasound blood-flow imaging studies with or without magnetic resonance angiography (MRA) or contrast angiography are used to visualize the arch, carotids, and vertebral vessels. This allows accurate documentation of any areas of stenosis as well as the extent of the collateral blood supply. Surgical improvement is minimal in patients with complete occlusion of the internal carotid artery, and operation is not recommended for patients with established long-standing occlusion. The risks of increasing cerebral damage or of the patient suffering hemiplegia are ever present, and the patient and family should be thoroughly informed of the risks.

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A thorough medical evaluation of the cardiovascular system with special attention to the coronary arteries is indicated. Other medical problems, including diabetes, must be under complete control. The incidence of stroke is greater in patients with contralateral carotid occlusion, and one-stage bilateral carotid endarterectomy is inadvisable because of the increased incidence of complications. At least a week or more should separate two procedures. The operation may be delayed in patients with acute strokes, allowing them to stabilize for 4 to 6 weeks, but there is increasing evidence that earlier intervention may be indicated in specific cases. At that time, imaging studies and operation can be considered.

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POSITION

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The patient is placed in a supine position with the head slightly extended and turned toward the contralateral side.

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OPERATIVE PREPARATION

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After routine skin preparation, the operative field is draped to expose the mastoid process superiorly, the angle of the mandible anteriorly, the manubrium and clavicle inferiorly, to the trapezius posteriorly.

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INCISION AND EXPOSURE

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The incision is made along the anterior border of the sternocleidomastoid muscle from the mastoid process to a point two-thirds of the distance to the sternoclavicular joint (figure 1). The incision is carried through the platysma muscle exposing the anterior border of the sternocleidomastoid muscle, which is then retracted laterally to expose the carotid sheath. Care must be taken to avoid making the upper end of the incision too far anteriorly, where the marginal mandibular branch of the facial nerve may be injured in its course just inferior to the horizontal ramus of the mandible. Such an injury results in paralysis of the lower lip. In the ...

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