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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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356 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Insertion of Shunt Tube into
Internal Carotid Artery
We use an internal shunt tube in all our patients, because monitoring such as EEG and SEP is not perfect. The
ICA is incised to the point where the plaque disappears, and then the internal shunt tube is inserted into the ICA.
During this procedure, the shunt tube must be inserted with the greatest care to avoid damaging the intima and
causing arterial dissection.
CHAPTER 4B: SURGICAL TECHNIQUE 357
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Insertion of Shunt Tube into
Common Carotid Artery
Next, the bulldog forceps that are blocking the CCA are removed and blood ow is blocked with the ngers. A
well-timed insertion of the internal shunt tube into the CCA can reduce bleeding from the CCA to almost zero.
After inating the balloon at the end of the internal shunt tube, the balloon is secured with a tourniquet. The time
it takes to clamp the carotid artery to insert the internal shunt tube into the carotid artery is usually 3–4 minutes.
358 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
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Observation of Plaque Content
After the internal shunt tube is unblocked and blood ow is restored, the nature of the plaque is closely monitored. In this case, the majority of the plaque had a necrotic core and was extremely fragile.
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Start of Endarterectomy
Dissection of plaque can be started from a relatively healthy part of the CCA on the anterior side to correctly
identify the plane to be dissected. A thin-bladed dissector is extremely useful for intimal dissection. The dissection procedure is continued to the distal end.
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Endarterectomy on the
Opposite Side
Similarly, on the opposite side, endarterectomy should be carefully performed from the CCA to the ICA.
CHAPTER 4B: SURGICAL TECHNIQUE 361
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Sharp Transection in Common
Carotid Artery
When the plaque has been dissected circumferentially, the proximal end of the plaque is cut using microscopic
scissors.
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Sharp Transection in Internal
Carotid Artery
As with the CCA, the distal end of the plaque is carefully cut with microscopic scissors in the ICA as well. The
cut ends are trimmed and made as sharp as possible.
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Sharp Transection in External
Carotid Artery
Finally, the plaque in the ECA is cut with microscopic scissors at the distal end as far as possible by dissecting
the plaque from the periphery. The ECA should be carefully observed for thick plaque remaining at the cut end
of the plaque. This is because thick plaque is a risk for post-operative ECA obstruction.
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Placement of Tacking Suture
in Internal Carotid Artery
We perform a tacking suture on ICA plaque margin in order to eliminate the possibility of post-operative detachment from the ICA by blood ow, which could be a source of embolization or obstruction of the ICA. We use a
6-0 Prolene or 6-0 Premio for tacking sutures at 4 and 8 o’clock with a shelf-crossing fashion.
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Primary Closure in Internal
Carotid Artery
We do not use patch grafts to suture the carotid artery and perform a primary closure in all cases. Our data show
that the incidence of acute post-operative occlusion and restenosis is less than 1% in all cases. We start suturing
the carotid artery from the distal ICA side. A little distal to the carotid incision, the 6-0 Prolene or 6-0 Premio is
used to make a continuous suture.
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