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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3660_Библиотеки_им_академика_М_И_Перельмана
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206 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Isolation of Ascending
Pharyngeal Artery (Right)
In this particular case, the gure illustrates another ascending pharyngeal artery that arose from the carotid
bifurcation. In this instance, I thought I had isolated all branches of the carotid tree but was troubled by brisk and
persistent backbleeding after opening of the carotid system. Because of my inability to complete the repair under
these circumstances, I performed an extensive search for the cause of this backbleeding artery, which nally
proved to be an ascending pharyngeal artery that was plastered up against the ICA. When this was dissected
free, it was possible to place a small bulldog clamp across it, which totally stopped the bleeding.
Note that because of the substitution of a better photograph for the second edition, the artwork depicts
an open ICA and a bulldog clamp on the ascending pharyngeal, while the new photograph shows a closed ICA
pre-arteriotomy and an encircling silk tie. The principles remain the same.
CHAPTER 4A: SURGICAL TECHNIQUE 207
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208 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Clues to the End of the ICA
Plaque
We use information from the angiogram to inform and show us how high we need to expose up the ICA to be
certain we are well beyond the end of the plaque. Shown here is a left lateral carotid angiogram in a patient with
a short neck and a routine height carotid bifurcation. The top of the ICA plaque is so labeled, and we know we
need to be at this point or above. We can guide ourselves in surgery by the ECA branches, which will be exposed
in the dissection. So, in this case, by reviewing the angiogram, when at surgery we are at the height of the second
major ECA branch (marked on the illustration), we know that we are at or above the distal extent of the ECA
plaque, and can be reassured that it is now prudent to begin the endarterectomy itself.
CHAPTER 4A: SURGICAL TECHNIQUE 209
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210 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Tactile and Visual End of
Plaque—Left Carotid Exposure
With some experience, it is possible to ascertain the end of the ICA atherosclerotic plaque by visual inspection
and tactile palpation of the vessel. It is important to determine this parameter because distal control must be
obtained well beyond the end of the plaque in case placement of a shunt is necessary and also because it would
be unwise to potentially cross-clamp an ICA across an area of atheroma.
This gure demonstrates the visual cues that indicate the end of the plaque—in particular, the yellowish
shade of the atherosclerotic carotid wall, which turns to a pink/blue color beyond the end of the atheroma.
In this case, vascular pickups were placed for demonstration purposes at the portion of the vessel where this
transition zone occurs. Likewise, palpation of this vessel would reveal a hard stony plaque in the region of the
atheroma and a soft, smooth pliable vessel distal to it. Note that the silk tie encircling the ICA has been placed
well above the end of the plaque and a nice high ICA exposure has been achieved. In this particular gure, the
vagus nerve lying lateral and deep to the ICA can also be seen.
CHAPTER 4A: SURGICAL TECHNIQUE 211
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212 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Tactile and Visual End of
Plaque—Right Carotid
Exposure
A low-power, more general view of a right carotid artery ready for cross-clamping provides a good example of
the visual end of atheromatous plaque. The bayonet illustrates the end of the tactile and visual atheroma, and an
ICA exposure was developed well above this region.
CHAPTER 4A: SURGICAL TECHNIQUE 213
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214 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Doppler Auscultation for Extent
of Plaque
The handheld sterile Doppler probe, which is readily available in the operating room, is also a useful way to listen for the increase in luminal velocity (higher pitched sound) when the distal end of the ICA plaque is reached.
We routinely use the Doppler to map out the extent of the plaque before opening the vessel. This photo shows
the Doppler probe on the proximal CCA, and while we like to listen there also, it is really at the ICA end that the
information is the most useful to the surgeon.
CHAPTER 4A: SURGICAL TECHNIQUE 215
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