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A Case of Carotid Artery Reconstruction

This 64-year-old female underwent cerebral angiography during evaluation of dizziness and headache. No intracranial cerebrovascular pathology was identified; however, 90% occlusion of the left internal carotid artery was revealed (Fig. 25–1). The risks, benefits, and alternatives to surgical carotid artery reconstruction for asymptomatic occlusive disease were discussed with the patient, and she agreed to proceed to surgery.

Surgical Technique

A baseline electroencephalogram (EEG) was obtained preoperatively. After receiving intravenous antibiotics in the holding area, the patient was taken to the operative suite and placed upon the operating room table in the supine position. Adequate general endotracheal anesthesia was induced and maintained throughout the case. An indwelling arterial line was inserted by the anesthesiologist for continuous blood pressure monitoring. An interscapular roll was placed to provide neck extension and thus high exposure. The head was turned away 45 degrees and the chin was taped to pull the mandible superiorly. Likewise, the ear lobule was taped anteriorly. The proposed incision was marked anterior to the sternocleidomastoid muscle extending from the clavicle inferiorly to the mastoid superiorly. It is rarely necessary to use the entire marked incision; however, preparing for extensive exposure is important. Infiltration of the proposed incision with 0.5% lidocaine and 1:200,000 parts epinephrine at least 5 minutes prior to incision reduces skin bleeding. In addition, liberal use of bovie and bipolar cautery in addition to loupe magnification optimizes visualization. The common facial vein crosses the carotid artery bifurcation prior to joining the jugular vein, and it was suture and clip ligated. Upon visualization of the carotid artery 5000 U of intravenous heparin was administered. Attention was then turned to exposure and proximal control of the common carotid artery. Once proximal control was established the external and internal carotid arteries were exposed, and the superior thyroid artery was encircled with a looped tie to provide temporary occlusion. Visual and Doppler inspection of the artery was then used to plan and mark the arteriotomy, which must span the plaque length (Fig. 25–2

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