Carotid Endarterectomy and Patch Plasty (with Optional Intraluminal Shunting)

Step 1: Skin incision and exposure

1. Longitudinal incision at the anterior edge of the sternocleidomastoid muscle (if it is necessary to access the distal ICA, the incision has to extend behind the ear)
   Alternative: Transverse incision
2. Upper border of the exposure is the digastric muscle, lower border the omohyoid muscle
3. Ligation of the facial vein and identification of the carotid bifurcation
4. Identification of the external carotid artery (ECA) and the inferior thyroid artery (vessel loop on each)
5. Exposure of the common carotid artery (CCA), umbilical tape and tourniquet (watch the vagal nerve)
6. Exposure of the internal carotid artery (ICA) on the anterior side, no vessel loop (especially in symptomatic patients, clamping of the CCA before dissection of the ICA is recommended)
7. Optional: identification of the hypoglossal nerve
8. No/minimal touch of the site of the stenosis

Step 2: Conventional endarterectomy

1. Clamping of the ICA, the CCA and the ECA (memorize: ICE)
2. Longitudinal incision from the distal CCA into the proximal ICA
3. Optional: shunt insertion
   1. Vessel loop on the ICA (to hold the shunt in place later)
   2. Shunt insertion into the CCA, fasten shunt with vessel loop and tourniquet
   3. Flushing, removal of air bubbles
   4. Removal of the ICA clamp
   5. Shunt insertion in the ICA under back-bleeding conditions (watch our for air bubbles and avoid distal dissection of the artery by the shunt!), fasen shunt with previously placed vessel loop
4. Local endarterectomy under visual control
5. Control of the distal end of endarterectomy, fixate the distal intima flap using 6/0 or 7/0 tacking sutures

Step 3: Patch plasty of the carotid bifurcation

1. Patch plasty with bovine pericardium, vein or Dacron prevents narrowing of the vessel by the suture and is the standard method for closure of the longitudinal arteriotomy after carotid endarterectomy. (Direct suturing of the arteriotomy may only be performed in highly selected cases)
2. Selection of an appropriately sized patch
3. sewing in the patch with a 6/0 running polypropylene suture
4. Before completing the running suture: Shunt removal and flushing of the CCA, the ECA and the ICA
5. Completing the running suture and knotting
6. Declamping of the ECA first, CCA second and ICA last (whatch figures)
7. Completion angiography (optional) or on table duplex sonography

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Control of educational objectives (tutor and trainee)

1. Clear cut arteriotomy, extending beyond the level of the disease proximally and distally
2. Declamping in correct sequence
3. No excessive bleeding, narrowing or kinking of the reconstruction
4. Outside aspect: knot and suture tightness, patch width, eversion, distance between sutures, suture of CCA and ACI corner
5. Inside aspect: Eversion, distance between stitches, suture of CCA and ACI corner

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