Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3660_Библиотеки_им_академика_М_И_Перельмана
.pdf
266 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
https://t.me/medicina_free
4-67
Opening of External Carotid
Artery—Part 1: Inadequate
Feathering
Marsupialization of the plaque from the ECA is usually sufcient to ensure a clean break-off. However, if fragments can be palpated or a rough edge can be demonstrated on inspection of the endarterectomized ECA with
a curved clamp, I do not hesitate to open the ECA with a separate arteriotomy that begins at the carotid bifurcation, extends straight up the ECA, and is performed in the same fashion as the ICA arteriotomy, creating a
Y-shaped arteriotomy defect that needs to be closed in that manner. Inattention to detail in the performance of
the ECA endarterectomy can be the source of thrombus formation and later embolization up the ICA, or it may
lead to a dissection of the ECA (illustrated in Fig. 3-21), which may ultimately cause thrombosis of the entire
carotid tree with devastating consequences for the patient.
In the case illustrated here, the ECA has been opened as a separate limb of the original arteriotomy. The
Peneld No. 4 dissector reveals a tail of plaque, which was incompletely removed in the marsupialization technique and which now must be dissected free, well up the ECA to the level of the bulldog clamp in just the same
fashion as for the ICA endarterectomy. Likewise, if plaque appears to extend beyond the bulldog clamp, this can
be released briey, allowing the plaque to be pulled back for a clean distal break-off. I cannot emphasize strongly
enough the need for attention to detail in the performance of the ECA endarterectomy and would urge that the
ECA be opened in every case in which even the slightest concern exists regarding thorough plaque removal.
CHAPTER 4A: SURGICAL TECHNIQUE 267
https://t.me/medicina_free
268 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
https://t.me/medicina_free
4-68
Opening of External Carotid
Artery—Part 2: Inadequate
Feathering
This is another illustration of, in this case, a right CEA in which the ECA was opened as a separate arteriotomy.
An area of rough plaque that did not readily marsupialize can be seen right at the orice of the ECA. I thought
a formal endarterectomy was necessary to adequately clean up the ECA and, as shown in this gure, made a
separate incision directly up the ECA to the level of the 2-0 silk tie.
CHAPTER 4A: SURGICAL TECHNIQUE 269
https://t.me/medicina_free
270 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
https://t.me/medicina_free
4-69
Opening of External Carotid
Artery Because of Poor
Doppler Signal
In this case, I had completed the internal carotid repair with Hemashield patch grafting. On nal auscultation
(after de-clamping), the Doppler signal from the ECA was high-pitched consistent with persistent stenosis. Fortunately, a shunt had not been required. The clamps were reapplied and the ECA was opened over a short distal
segment and residual plaque was removed. Following this strategy, as previously illustrated, a primary ECA
repair without patch graft was performed, although in this case it did not extend back to the carotid bulb.
CHAPTER 4A: SURGICAL TECHNIQUE 271
https://t.me/medicina_free
272 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
https://t.me/medicina_free
4-70
Opening of External Carotid
Artery—Repair
This is a left CEA in which it was necessary to open and repair the ECA as a separate incision. In this case, the
common to internal carotid arteriotomy remains open and the denuded area of vascular wall following plaque
removal can be seen. A suture line is begun in the ECA and brought down in continuous, non-locking fashion to
the region of the carotid bulb where it is secured to a separately thrown single 6-0 Prolene stitch. The long tail of
this stitch is then tied to one of the limbs of the main suture line when the common and internal carotid arteries
are repaired. It is important to note that when I do open the ECA separately, I repair it rst since there is a rather
limited amount of time available for completion of the arterial suture line at the junction of the common and
internal arteries, particularly in shunted cases.
CHAPTER 4A: SURGICAL TECHNIQUE 273
https://t.me/medicina_free
274 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
https://t.me/medicina_free
4-71
Completed External Carotid
Artery Repair in a Case with
Internal Carotid Artery
Hemashield Patch
This photograph shows the nal result in a case where an ICA Hemashield patch was used and the ECA was
opened secondarily for poor Doppler signal. The eld is dry and the repair is secure at both the primary and the
patch closure sites. The clamps have been removed and ow is re-established with no bleeding or leaks.
This photograph also illustrates well the use of the four retention sutures to hold open the carotid sheath
and improve the vascular exposure.
CHAPTER 4A: SURGICAL TECHNIQUE 275
https://t.me/medicina_free
Соседние файлы в папке Библиотека им академика М.И. Перельмана