Surgical Technique for Carotid Endarterectomy: Current Methods and Problems

Abstract

Over the last 60 years, many reports have investigated carotid endarterectomy (CEA) and techniques have thus changed and improved. In this paper, we review the recent literature regarding operational maneuvers for CEA and discuss future problems for CEA. Longitudinal skin incision is common, but the transverse incision has been reported to offer minimal invasiveness and better cosmetic effects for CEA. Most surgeons currently use microscopy for dissection of the artery and plaque. Although no monitoring technique during CEA has been proven superior, multiple monitors offer better sensitivity for predicting postoperative neurological deficit. To date, data are lacking regarding whether routine shunt or selective shunt is better. Individual surgeons thus need to select the method with which they are more comfortable. Many surgical techniques have been reported to obtain distal control of the internal carotid artery in patients with high cervical carotid bifurcation or high plaque, and minimally invasive techniques should be considered. Multiple studies have shown that patch angioplasty reduces the risks of stroke and restenosis compared with primary closure, but few surgeons in Japan have been performing patch angioplasty. Most surgeons thus experience only a small volume of CEAs in Japan, so training programs and development of in vivo training models are important.

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

“…After establishment of the airway (AW), the patient is placed in a supine position, arms along the body, and with hyperextension and contralateral rotation of the neck, facilitating more distal dissection of the ICA. 21 , 34 , 63 However, excessive movements can cause compression of the vertebral arteries or the contralateral carotid, 64 in addition to making SCM muscle retraction difficult because of increased muscle tension and restricting the mobility of the CCA and the carotid bifurcation. 65…”

“…Após o estabelecimento da via aérea (VA), o paciente é colocado em posição supina, com os braços ao longo do corpo, hiperextensão e rotação contralateral do pescoço, facilitando a dissecção mais distal da ACI 21 , 34 , 63 . Entretanto, movimentos excessivos podem resultar em compressão das artérias vertebrais ou da carótida contralateral 64 , além de dificultar a retração do ECM por aumentar a tensão do músculo e restringir a mobilidade da ACC e da bifurcação carotídea 65 .…”

In vivo endothelialization and neointimal hyperplasia assessment after rabbit carotid endarterectomy with bovine pericardium

“…A subgroup analysis of the CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) study showed that the use of a patch in CEA could significantly reduce the occurrence of restenosis after 2 years compared with DC (3.1% vs. 10.7%, hazard ratio =0.35) (5). At present, the use of patches may present some challenges, such as prolonged operation time, graft-related infection, thrombosis, aneurysmal dilatation, and other issues (11,25). However, few studies have compared the intimal growth between PC and DC after CEA.…”

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

“…After establishment of the airway (AW), the patient is placed in a supine position, arms along the body, and with hyperextension and contralateral rotation of the neck, facilitating more distal dissection of the ICA. 21,34,63 However, excessive movements can cause compression of the vertebral arteries or the contralateral carotid, 64 in addition to making SCM muscle retraction difficult because of increased muscle tension and restricting the mobility of the CCA and the carotid bifurcation. 65 Surgical AW and nasotracheal intubation (NTI) increase the number of possible techniques for exposure of the DCSICA or an HCB, making temporary mandibular subluxation (TMS) a viable option.…”