Subluxação da mandíbula para abordagem de bifurcação carotídea alta em paciente com parotidite por contraste iodado: relato de caso e revisão de literatura

Abstract

Atherosclerotic disease of the extracranial carotid arteries can cause complications with high morbidity and mortality rates. The contrast imaging examinations used in preoperative evaluation are associated with complications such as parotitis, in addition to well-known allergic reactions and renal dysfunction. A high carotid bifurcation or atherosclerotic disease that extends distally are often limiting factors for conventional surgical treatment. However, when iodinated contrast is contraindicated or endovascular treatment is not feasible, knowledge of surgical techniques that allow safe endarterectomy is required. Subluxation of the mandible has proven to be a safe and effective adjuvant technique that is easy to perform and reproducible, providing access to high carotid bifurcations with good exposure of the surgical field and allowing endarterectomy to be performed with a standard technique. We present the case of a patient with a high carotid bifurcation and limitations for use of iodinated contrast who underwent carotid endarterectomy after subluxation of the mandible.Keywords: carotid artery diseases; parotitis; endarterectomy; angioplasty; jaw fixation techniques; mandible. ResumoA doença aterosclerótica das carótidas extracranianas pode resultar em complicações com alta morbidade e mortalidade. A avaliação pré-operatória com exames contrastados de imagem é associada a complicações como a parotidite, além das já bem conhecidas reações alérgicas e da disfunção renal. A bifurcação carotídea alta e a doença aterosclerótica de extensão cranial costumam ser fatores limitantes para o tratamento cirúrgico convencional. Entretanto, quando há contraindicação ao uso de contraste iodado ou impossibilidade do tratamento endovascular, há a necessidade do conhecimento de técnicas cirúrgicas que permitam a realização da endarterectomia com segurança. A subluxação da mandíbula se mostrou uma técnica adjuvante segura e efetiva, de fácil execução e reprodutibilidade, possibilitando o acesso a bifurcações carotídeas altas com boa exposição do campo cirúrgico e permitindo a realização da endarterectomia conforme a técnica padrão. Apresentamos o caso de uma paciente com bifurcação carotídea alta e com limitações para uso do contraste iodado que foi submetida a endarterectomia carotídea após subluxação de mandíbula.

Acesso cirúrgico ao segmento cervical distal da artéria carótida interna e à bifurcação carotídea alta – revisão integrativa da literatura e proposta de protocolo

“… 58 However, significant anatomic variations have been described, including bifurcation at the levels of T4 and Cl. 59 By convention, the carotid bifurcation is defined as “high” if it occurs cranial of C3/C4, above the hyoid bone/thyroid cartilage 58 , 60 or above the Blaisdell line (a line traced between the tip of the mastoid process and the angle of the mandible) 27 and “low” if it occurs below these anatomic references. 58 , 60 …”

“…Entretanto, variações anatômicas significativas foram descritas, incluindo os níveis de T4 e Cl 59 . Por convenção, a bifurcação carotídea é considerada “alta” quando ocorre cranialmente à C3/C4, acima do osso hioide/cartilagem tireoide 58 , 60 ou acima da linha de Blaisdell (linha projetada entre o ápice do processo mastoide e o ângulo da mandíbula) 27 e “baixa” quando ocorre inferiormente a essas referências anatômicas 58 , 60 .…”

Surgical access to the distal cervical segment of the internal carotid artery and to a high carotid bifurcation – integrative literature review and protocol proposal

“…58 However, significant anatomic variations have been described, including bifurcation at the levels of T4 and Cl. 59 By convention, the carotid bifurcation is defined as "high" if it occurs cranial of C3/C4, above the hyoid bone/thyroid cartilage 58,60 or above the Blaisdell line (a line traced between the tip of the mastoid process and the angle of the mandible) 27 and "low" if it occurs below these anatomic references. 58,60 After the CCA bifurcation, the ICA follows an ascending path within the carotid sheath, posteromedial of the internal jugular vein and the vagus nerve, to the carotid canal in the temporal bone.…”

“…5 Next, the majority of authors recommend dissection along the anterior (medial) margin of the SCM muscle for lateral retraction. 3,[5][6][7][8][9][10][11][12][13][14][15][16][17]21,23,[25][26][27][28][32][33][34][35][36][37][38]40,[44][45][46][47][48][49][50][52][53][54][55][56][57] The facial vein should be ligated and the hypoglossal loop can be sectioned, exposing the entire cervical portion of the CCA and a mean of 26.95 mm (varying from 15 to 45 mm) 5 of the proximal segment of the ICA, equivalent to the level of the upper third of C2. 8,30 However, dissections via posterior routes are also described, such as the retrojugular access 30 and via the retromandibular fossa.…”

“…The correct position after subluxation of the condyle can be easily confirmed by inspection and palpation of the lateral aspect of the condyle immediately below the articular eminence. 3 With regard to complications, from clinical studies published on SMT (investigating 217 patients), 12 reported absence of symptomatic temporomandibular dysfunction during the postoperative period; 3,15,16,19,20,[22][23][24][25][26][27][28] one did not report information on complications; 18 and just two studies 17,21 described patients with painful symptoms involving the temporomandibular joint (TMJ) during the postoperative period, all cases of which exhibited complete clinical resolution in a few weeks with analgesia alone. Tables S2 (available online as a supplementary file) and 4 list these studies and practical aspects related to TMS.…”