Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3660_Библиотеки_им_академика_М_И_Перельмана

When the arteriotomy is complete and the decision has been made whether or not to shunt, plaque removal begins. I start at the lateral edge of the vessel using a Peneld No. 4 micro-dissector or a Freer dissector and rub gently back and forth along the vessel wall. In a primary case, it usually falls into a cleavage plane just outside the atheromatous intimal plaque, which is easily dissected. Gentle dissection is required to avoid buttonholing the residual vessel wall, which may be quite thin. I prefer the Peneld micro-dissector, which is always turned medially so that no sharp edge extends through the plaque into the vessel wall. The dissection continues in a cir­cumferential fashion approximately halfway around the vessel, and the same process is repeated on the medial side. Dissection also proceeds in a rostral-caudal direction in an attempt to gently free up both the ICA attach­ments of the plaque and the CCA, which is prepared for sharp transection.

When the plaque has been dissected circumferentially from the lumen of the carotid bulb and CCA, it is usually not possible to follow it far enough down the CCA to obtain a feathered edge, as is done in the ICA. I prefer to sharply transect the CCA plaque at the point where the caudad dissection ends. This can be accomplished with either a No. 15 blade or, as in this case, Church Scissors. Once again, it is important to identify the back wall of the vessel so that it is not inadvertently buttonholed by either cutting technique. Once the plaque has been sharply removed from the CCA, it can be held up with the vascular forceps and removed from the internal and external carotid arteries.