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
276 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
https://t.me/medicina_free
4-72
Removal of Fragments in
Circumferential Fashion—Right
Carotid Exposure
Before beginning the repair of the arteriotomy, it is necessary to inspect the bed of the carotid plaque for any
loose fragments that might need to be removed. Failure to attend to this detail may result in free fragments of
material in the arterial lumen, which can create the nidus for thrombus formation and subsequent embolization.
I prefer to gently stroke the denuded area with a small peanut sponge, which brings up any loose edges, particularly if the stroking is done in a caudad to cephalad direction. Fragments should be grasped with the vascular
forceps and peeled off in circumferential fashion. If the removal process is begun either in the center of the vessel
or on one edge, the fragment will peel off in a circular fashion until it reaches the other edge of the arteriotomy.
It is important to avoid further traumatizing of the denuded area.
Areas of retained intima that are solidly attached to the vessel wall need not be dissected free. Only areas
with a loose edge and which readily submit to circumferential removal need to be scrupulously eliminated from
the arterial bed.
CHAPTER 4A: SURGICAL TECHNIQUE 277
https://t.me/medicina_free
278 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
https://t.me/medicina_free
4-73
Left Carotid Endarterectomy—
Completed Removal, Sharp
Margins
After completed removal of the plaque from the internal, common, and external carotid arteries, a denuded area
of vessel wall is seen and the arteriotomy is ready for arterial repair to begin. In this gure, note the sharp margin
where the normal shelf of intima begins in the ICA. Whether this particular example would require a tacking
stitch would depend on how it responded to palpation and whether the surgeon believed it represented a loose
edge. The yellow area of the sharp removal of plaque can be seen peeking out from the arteriotomy edge at the
CCA as well. Once the fragments have been removed in circumferential fashion, the vessel is ready for arterial
repair, which begins distally in the ICA.
CHAPTER 4A: SURGICAL TECHNIQUE 279
https://t.me/medicina_free
280 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
https://t.me/medicina_free
4-74
Completed Removal, Sharp
Margins—Left Carotid Exposure
A second example shows a somewhat closer view of a sharp margin after removal of the plaque in its entirety
from the common, internal, and external carotid arteries. In this particular case, the plaque is feathered nicely
from the ICA and there is no visible need to place tacking sutures. All fragments appear to have been removed,
and the vessel is ready for surgical repair of the arteriotomy.
CHAPTER 4A: SURGICAL TECHNIQUE 281
https://t.me/medicina_free
282 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
https://t.me/medicina_free
4-75
Placement of Tacking Sutures
in Internal Carotid Artery
As mentioned, I do my best to follow the atheroma up high enough in the ICA, so that it feathers completely,
leaving a smooth transition zone without the need for tacking sutures. However, there is no question in my mind
that in perhaps 10%–20% of cases I am dissatised with the transition zone and I believe that tacking sutures
should be placed.
When this is necessary, I try to place tacking sutures in three positions in the circumference of the arterial
wall. They are placed posteriorly at the 4 and 8 o’clock positions, and the third is a de facto tacking suture placed
by picking up all levels of the vessel wall in the repaired arterial suture line at essentially 12 o’clock position. The
sutures are double-armed 6-0 Prolene that are passed from the inside out to cross the shelf of the intimal edge.
The knot can then be tied outside the vessel wall so that no thrombogenic knot or loose end is left within the
vessel lumen. It is important to place these sutures accurately because once they are tied, it is essentially impossible to remove them. Gently stroking with a peanut sponge will then indicate whether the loose ap has been
adequately secured.
CHAPTER 4A: SURGICAL TECHNIQUE 283
https://t.me/medicina_free
284 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
https://t.me/medicina_free
4-76
ICA Single Posterior Tacking
Suture
Figure 4-74 showed a transition zone smooth enough and adherent enough that no extra steps were needed to
protect against ap development after reconstitution of ow. To illustrate the other possibility, this is a closein photo of an ICA transition zone that we felt needed one posterior tacking suture. The suture has effectively
secured the posterior wall so that the distal intima will not lift from the endartrectomized segment when antegrade ow is restored. The suture of 6-0 Prolene is so small that it is not visible, but the tacked down area is clear
in the center of the transition, and actually in the center of the photo itself.
CHAPTER 4A: SURGICAL TECHNIQUE 285
https://t.me/medicina_free
Соседние файлы в папке Библиотека им академика М.И. Перельмана