Preoperative Diagnosis:
70% right internal carotid artery stenosis.

Postoperative Diagnosis:
Same.

Procedure: Right carotid endarterectomy with PTFE patch angioplasty.

Anesthesia: General endotracheal.

Indications for Procedure: The patient is a 74-year-old male who is status post right carotid endarterectomy for 90% occlusion approximately 9 months ago. For the past 3 months he has been experiencing paresthesias of the right arm, headaches, visual disturbances, and occasional difficulty with speech. A bilateral carotid color duplex exam revealed 50% stenosis of the left internal carotid artery, and an 80% reocclusion of the right internal carotid. The patient presents for repeat right carotid endarterectomy.

Description of Procedure: With the patient under well tolerated general anesthesia with the head turned to the left, the right neck and anterior chest were prepped and draped in the usual sterile fashion. An oblique incision along the anterior border of the sternocleidomastoid muscle was performed with the scalpel and the subcutaneous tissue and platysma were divided with electrocautery.

Dissection was performed at the root of the carotid sheath and the rather large common carotid artery was carefully encircled and controlled with umbilical tape. Care was taken to identify and avoid injury to the vagus nerve and jugular vein. Cephalad dissection was performed and there were actually two large crossing venous branches from the internal jugular towards the fascial tissues. These were gently dissected free from the surrounding tissue to ensure that there were no adjacent nerve structures, and then doubly ligated and divided with 3-0 silk ligatures.

The dissection above the level of the plaque was performed in the internal and external carotid arteries, and they were each carefully encircled with umbilical tape.

Because of the size of the artery it was felt that patching would not be necessary. Therefore, no blood for preclotting the Dacron prosthesis was obtained prior to heparin administration. 7000 units of intravenous heparin were administered, and after awaiting a 4 minute circulation time the internal carotid artery was gently occluded, followed by the common and external carotids.

An anterolateral arteriotomy was fashioned from the common carotid artery up into the internal carotid artery, and a shunt was then placed first into the internal carotid artery. After allowing backbleeding to remove air bubbles and debris, the shunt was placed into the common carotid artery. The plaque was tenacious, particularly in the carotid bulb. Its removal created significant fraying of the vessel wall edges with a cordlike spiral extension which required very delicate removal distally.

Eventually a smooth end point was obtained with only a mild intimal ridge. This was tacked posteriorly with interrupted sutures of 7-0 Surgilene. Because of the attenuous nature of the vessel edge it was felt prudent to trim back this irregular tissue which thus necessitated a patch closure to ensure adequate vessel lumen.

A thin-walled 10 mm. PTFE vascular conduit was obtained and cut to the appropriate dimensions to form an elliptical patch. After using the heparin irrigation to remove other smooth muscle strands and debris, the patch was sutured into position using running continuous sutures of 6-0 Surgilene. Prior to placement of the final sutures, retrograde and prograde flushing was done, and the shunt was removed. The suture line was then complete and flow was observed to be restored through several cardiac cycles. Suture line bleeding was controlled with thrombin-soaked Gelfoam and pressure. A continuous wave Doppler was used to ensure adequate Doppler signal in both carotid branches.

Once hemostasis was achieved, a Jackson-Pratt drain was placed through a separate stab wound at the base of the neck and the wound was closed in two layers using interrupted 3-0 Vicryl for the subcutaneous tissues and staples for the skin.

At the end of the case, all sponge and needle counts were correct times two. The patient tolerated the procedure well. He was transferred to the surgical ICU in stable condition.