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126 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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FIGURE 3-31
Radiological and intra-operative ndings in a 72-year-old male with left carotid artery stenosis. 3D-CTA clearly demonstrated that the distal
end of carotid plaque is located at the C1/2 level of cervical vertebrae (arrow). The mandibular angle and the occipital artery (arrowheads)
can be used as good landmarks for surgical planning. Observation during carotid endarterectomy revealed that the carotid bifurcation was
located at almost same level of the hypoglossal nerve (upper panel, arrow). The posterior belly of the digastric muscle and parotid gland
were dissected and retracted. Then, the distal internal carotid artery was dissected rostral to the hypoglossal nerve (lower panel, arrow).
FIGURE 3-32
CTA for assessing the access route of CAS. Note multiple plaques in the wall of the aorta (so-called “shaggy aorta”) and the ostial stenosis
of the left common carotid artery (arrow). This patient was evaluated at high risk of thromboembolic complications such as cerebral/renal
embolism and blue toe syndrome.
CHAPTER 3: RADIOGRAPHIC STUDIES 127
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FIGURE 3-33
Left: 3D-CTA showing the access route from the aorta and the carotid artery. This Type-3 aortic arch suggested a slight difculty in approaching to the right carotid artery. Right: 3D–DSA showing the measurement of carotid arteries. Based on these measurements, the size of a
pre-dilatation balloon (3.0 mm in diameter), a post-dilatation balloon (4.5 mm), and a stent (8 mm in diameter and 40 mm in length) was
determined.
FIGURE 3-34
(A) MR angiogram showing the stenosis of the left carotid artery. (B and C) T1 weighted images of the carotid plaque in sagittal (B) and
axial (C) views. (D) TOF (time-of-ight) source image in axial view. Note the high-volume lipid-rich plaque (T1 high and TOF iso-intensity).
Evaluating these data, the initial plan of treating with CAS was converted to CEA to avoid thromboembolic complications of CAS.
128 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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FIGURE 3-35
(A) MR angiogram showing the stenosis of the left carotid artery with a small amount of intra-plaque hemorrhage (arrow). (B) T1-weighted
image of the carotid plaque in axial view. (C) TOF (time-of-ight) source image of the plaque in axial view. Majority of the plaque consists of
a lipid-rich necrotic core with a small hematoma. Evaluating these data, CAS was performed with cerebral protection using the ow reversal
method (see Chapter 2).
FIGURE 3-36
(A and B) Carotid angiogram before (A) and after CAS (B). Combination of a distal lter and a proximal balloon protection method was used.
(C and D) MRI diffusion-weighted images on the next day of CAS, showing new asymptomatic multiple high spot intensity lesions (arrows)
as the thromboembolic complication of CAS.
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Xe-inhalation tomogra-
CHAPTER 4A
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Surgical Technique
Christopher Loftus
131
132 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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4-1
Surgical Instruments
Like most surgeons do, I have assembled for my personal use (and I treasure), a custom tray of surgical instruments specically for carotid surgery. Some of these instruments are standard favorites, while others have been
specially designed or modied by the Scanlan Company of St. Paul, Minnesota. For a number of years, I have
marketed, with Scanlan, the Scanlan-Loftus® carotid set, a complete set of essential instrumentation for carotid
procedures (A). In (B), we illustrate specically four Scanlan-Loftus scissors; two types of Potts Scissors to open
the vessel (large and small, depending on the vessel size and degree of calcication), and also two sets of specially designed Metzenbaum-type scissors, again large and small, which I use for the dissection and exposure
steps (large), and for ne work around the internal carotid or for plaque trimming in the CCA (small). In (C), I
have illustrated the large and small “bulldog” clamps I use for closure of the internal and external carotid arteries. The large strong clamp occludes the ECA nicely to prevent backbleeding, while the smaller weaker clamp
occludes the ICA without causing intimal damage. Finally, in (D), I show the simple Rummel-type tourniquet,
handmade by the scrub nurse, which I use (with an encircling 0 silk tie) to occlude the CCA around a shunt tube
if shunting is needed. If no shunt is required, the CCA is occluded throughout the case with a DeBakey-type
cross-clamp only.
Special Purpose Scanlan Loftus ICA Clamps: These are three special clamps that are part of the Scanlan
Loftus CEA instruments (E). Each has a specic purpose. On the left is a small vascular clamp that I use to close
the ICA if the usual bulldog clamp (shown in C) does not have sufcient force to hold it closed, and there is
backbleeding through the bulldog clamp. The middle and right photos show what I refer to as “dogleg” clamps.
These clamps are used when a high exposure far up the ICA is needed. The clamp lies underneath the CCA-ICA
complex and the offset jaws reach up underneath and behind the ICA to clamp it, potentially beyond where we
can customarily reach with the bulldog clamp. There is a specic clamp for each side. In this illustration, the
clamp in the center is used for a left-sided ICA surgery, and the clamp on the right would be used for a rightsided ICA surgery.
CHAPTER 4A: SURGICAL TECHNIQUE 133
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134 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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4-2
Surgical Positioning
The photograph and drawing in this gure demonstrate standard surgical positioning for a carotid endarterectomy (CEA). The patient is positioned with the head extended and turned somewhat to the opposite side
from the proposed surgical incision. The degree of head turning depends on the relationship of the internal and
external carotid arteries, whether side-by-side or conventional in position as outlined in Fig. 3-3 in Chapter 3,
Radiographic Studies, it will be turned more for a “side-by-side” carotid exposure. The head is allowed to fall
back on a foam donut, and ve or six folded towels or pillowcases are placed between and beneath the patient’s
shoulder blades, thereby permitting the shoulders to drop back, away from the surgical eld. If this is not done,
the surgeon will need to work over the bony shoulder prominence, which is awkward.
A vertical incision is made along the palpable anterior border of the sternocleidomastoid muscle. The incision can be placed somewhat higher or lower, depending on the height of the carotid bifurcation (Fig. 4-5). The
incision can be made as low as the sternal notch or can go well up behind the ear in cases in which a high bifurcation is anticipated. The angle of the mandible as visualized on the lateral angiographic lm can be drawn on the
skin and thus provide some idea of the approximate position of the carotid tree in relation to surface anatomic
landmarks.
CHAPTER 4A: SURGICAL TECHNIQUE 135
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