21: ARTERIOSCLEROTIC CAROTID OCCLUSIVE: SURGICAL

(A) Carotid endarterectomy (CEA) can be performed via a neck incision along the anterior border of the sternocleidomastoid muscle (red arrow). The inferior border of the mandible is indicated by the blue arrow. (B) The platysma is divided and the sternocleidomastoid muscle (blue arrow) and jugular vein are retracted laterally. The head end of the patient is towards the right side of the photos. Procedure is being performed on the left carotid artery.

(A) The vagus is preserved in the carotid sheath. (B) The hypoglossal nerve is encountered cephalad in the dissection (dark blue arrow). The internal carotid artery (ICA) is shown by the black arrow.

(A) The intraoperative carotid clamping is tolerated without neurologic compromise by greater than 85% of patients. The plaque is noted by the green arrow as soon as the carotid bifurcation is opened. Carotid endarterectomy (CEA) may be performed with or without intraoperative shunting (dark blue arrow); if done without shunting, cerebral monitoring of some kind is indicated to detect intolerance of clamping. This can be accomplished by using regional anesthesia with direct monitoring of mental status, or with general anesthesia using electroencephalogram, somatosensory-evoked potential, or internal carotid artery (ICA) stump pressure monitoring. (B) Endarterectomy may be done longitudinally as pictured or using an eversion technique without an effect on outcome, but if longitudinal endarterectomy is performed, patch angioplasty offers better stroke and restenosis rates than primary closure (blue arrow).