Surgical Technique for Carotid Endarterectomy: Current Methods and Problems

Masaaki Uno, Hiroki Takai, Kenji Yagi, Shunji Matsubara, Masaaki Uno, Hiroki Takai, Kenji Yagi, Shunji Matsubara

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.

Keywords: carotid endarterectomy surgical technique; high plaque; monitoring; shunt.

Conflict of interest statement

Conflicts of Interest Disclosure

The authors have no conflicts of interest to declare regarding this study or its findings.

Figures

Fig. 1
Fig. 1
Annual changes in CEA and CAS. These data are prepared with permission from The Japan Neurosurgical Society. CAS: carotid artery stenting, CEA: carotid endarterectomy.
Fig. 2
Fig. 2
Neck extension and head rotation. (A) Routine neck extension and head rotation (about 45°) to the opposite side. (B) Nasotracheal intubation and extensive rotation (≥45°) and extension for exposure of the distal internal carotid artery.
Fig. 3
Fig. 3
Skin incision for CEA. (A) Longitudinal incision along the anterior margin of SCM. (B) Transverse incision across the anterior margin of SCM. C: Combined incision, CEA: carotid endarterectomy, SCM: sternocleidomastoid muscle (#).
Fig. 4
Fig. 4
Photograph of the operative field. Using mini-hooks with rubber bands, the carotid artery is lifted to the surface. The surgical field is also widely developed using mini-hooks. CCA: common carotid artery, ICA: internal carotid artery, ECA: external carotid artery, yellow bar: cranial nerve X (vagus nerve), blue bar: cranial nerve XII (hypoglossal nerve), White bar: * mini- hooks with rubber bands.
Fig. 5
Fig. 5
Intraoperative monitoring for CEA. MEP, somatosensory evoked potential (SEP) and NIRS as intraoperative monitoring for CEA. BIS is used to monitor anesthesia. Red arrow, MEP electrode; yellow arrows, electrodes for SEP; blue arrow, electrode for NIRS; green arrow, electrode for BIS. BIS: bispectral index, CEA: carotid endarterectomy, MEP: motor-evoked potential, NIRS: near-infrared spectroscopic topography, SEP: sensory-evoked potential.
Fig. 6
Fig. 6
Definition of high plaque. (A) Definition of high plaque by Hans et al. The ICA is divided into three zones, with high plaque defined as that located above Zone 2. (B) Various definition of high plaque. Yellow line is the mastoid-mandibular line. Red line is the intersection of the occipital artery and internal carotid artery. White line is the C1 transverse process-hyoid bone line. ICA: internal carotid artery.
Fig. 7
Fig. 7
Dissection of the distal ICA. (A) Correlation of carotid arteries and lower cranial nerves. (B) Dissection of the distal ICA. Ansa cervicalis is cut and pulled up alongside the hypoglossal nerve. If the occipital artery (OA) and/or sternocleidomastoid muscle artery (SMA) prevent securing of the distal ICA, they should be cut. ICA: internal carotid artery.

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