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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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216 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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4-42
Extensive Plaque Erosion
into the Adventitial Layer
We occasionally encounter atheromatous plaques so extensive and erosive that they create an outpouching-type
ulceration into the outer layers of the carotid. Depending on surgeon preference, a number of strategies can be
called upon to x this. In this particular case, which is one of my earlier ones, I excised this area of outpouching and did an end-to-end anastomosis of the wall with interrupted 6-0 Prolene sutures. Today, I think instead I
would simply excise the wall widely and use the Hemashield patch to reconstruct a widely patent lumen. Without one of these strategies, the residual wall after endarterectomy would have been sufciently thin that I think
the patient would have been at risk for blowout if managed with only simple conventional endarterectomy and
primary repair. The surgeon must be prepared to embrace unusual and creative strategies when faced with these
types of variants.
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218 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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4-43
Javid Clamp around Internal
Carotid Artery
One method of securing a shunt in place is with a small Javid clamp. When the high exposure of the ICA is
obtained and the silk suture is passed around it for control, it is important to ascertain that adequate space has
been left for placement of the Javid clamp to secure an indwelling shunt if necessary. As shown here, a small
Javid clamp is placed from the lateral side and encircles the vessel as a test. The clamp can then be closed around
the vessel, securing the plastic shunt tubing in place. Without this type of preparation, it is possible that a lmy
veil of carotid sheath tissue behind the carotid artery will interfere with and prevent successful placement of the
Javid clamp later on and the resultant backbleeding around the shunt will be particularly troublesome.
I previously used Javid clamps but have switched to my own clamp design now (see Figs. 4-44 and 4-59).
The Javid clamp illustrations are retained, however, to demonstrate the various options available to the surgeon.
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220 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Loftus Shunt Clamps
This illustration shows three models of a spring loaded internal carotid shunt clamp of the author’s design,
manufactured by Scanlan Instruments of St. Paul, Minnesota. I previously used a Javid-type clamp to secure the
ICA around an indwelling shunt, but I was unhappy with the long handle protruding into the carotid bed. These
simple clamps pinch down gently and encircle the ICA, preventing backbleeding from the distal vessel. They
closing force is gentle to prevent intimal damage, and they come in various angles (as illustrated here) to allow
them to be custom sized and to remain unobtrusive in the wound.
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222 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Placement of Cross-Clamp
below Rummel Tourniquet
My technique of shunt insertion will be described later. This drawing is intended to illustrate that in preparation for placement of a shunt it is essential that the Rummel tourniquet that will secure the shunt in place be at
least 1 cm (hopefully farther) distal to the DeBakey cross-clamp. This entails dissection of a fair amount of CCA
to obtain a good proximal location for placement of the cross-clamp. The reason for this is that in order to avoid
copious bleeding with placement of the shunt in the CCA, it is my preference to place the shunt down in the
lumen of the vessel through the Rummel tourniquet loop until it abuts against the cross-clamp. The loop can then
be securely snugged down around it before the cross-clamp is removed. When the cross-clamp is then removed,
there is essentially no bleeding because the shunt has already been secured, but it is still possible to slide the
shunt farther down the CCA as it slips quite nicely through the loop. In this way, I have converted a procedure
that formerly produced copious bleeding into an essentially bloodless task.
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4-46
Incision along Common and
Internal Carotid Arteries
(Blue Line)—Left Carotid
Exposure
Shown is a carotid artery fully prepared for cross-clamping. Note that the superior thyroid artery and the external, internal, and common carotid arteries have all been secured with their respective loops and silk ties. Adequate exposure of the distal ICA has been obtained, and a long segment of CCA is available proximal to the
vessel loop so that the DeBakey clamp may be well below the vessel loop in case a shunt is needed.
Using a sterile marking pen, I draw a line indicating the area of proposed incision in the carotid artery to
prevent a jagged suture line if the vessel rotates as it is opened and to facilitate the repair.
After the encephalographer is notied of impending cross-clamping, I prefer to use a bulldog clamp to
close the ICA rst, followed immediately by DeBakey cross-clamping of the CCA and a second bulldog clamp
applied to the ECA below the level of any branches except the superior thyroid artery. Closing the ICA rst prevents any plaque that might become dislodged by the CCA cross-clamp from entering the cranial circulation.
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