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
416 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
https://t.me/medicina_free
CHAPTER 6: SPECIAL CASES 417
https://t.me/medicina_free
418 CAROTID TREATMENT: PRINCIPLES AND TECHNIQUES
https://t.me/medicina_free
CHAPTER 6: SPECIAL CASES 419
https://t.me/medicina_free
REFERENCE
1. Kashiwazaki D, Shiraishi K, Yamamoto S, Kamo T, Uchino H, Saito H, Akioka N, Kuwayama N, Noguchi K, Kuroda
S. Efcacy of carotid endarterectomy for mild (<50%) symptomatic carotid stenosis with unstable plaque. World
Neurosurg. 2019; 121:e60–e69.
https://t.me/medicina_free
Index
https://t.me/medicina_free
Note: Locators in italics represent gures in the text.
A
Abdominal aortic aneurysms, 62, 62
Abernathy, John, 2
ACAS, see Asymptomatic Carotid
Atherosclerosis Study
Acetazolamide (ACZ), 122
ACS, see Asymptomatic carotid stenosis
ACST, see Asymptomatic Carotid Surgery
Trials
Activated clotting times (ACT) value, 12
ACT value, see Activated clotting times
value
ACZ, see Acetazolamide
AHA guidelines, see American Heart
Association guidelines
American Heart Association (AHA)
guidelines, 5
Anesthesia, 16
general anesthesia, 18
local/regional anesthesia, 16–18
Aneurysm formation 4 years post-
operatively, 380–381
Angiogram, 2
Angiography, 2
Angioplasty, two-staged, 70
Antiplatelet-aggregating medications, 40
Antiplatelet therapy, 61
Arteriotomy techniques, 29
clamp removal sequence, 314–315
heparinization, 30
patch grafting, 29
tacking sutures, 30
ARU, see Aspirin response units
Ascending pharyngeal artery
isolation of
left, 204–205
right, 206–207
X-ray identication of, 94–95
Aspirin response units (ARU), 61
Asymptomatic Carotid Atherosclerosis
Study (ACAS), 4
Asymptomatic carotid disease, 3
asymptomatic bruit, 3–5
contralateral carotid stenosis, 5–6
Hollenhorst plaque, 6–7
non-carotid pre-operative patients,
carotid risks in, 6
Asymptomatic carotid stenosis (ACS), 12
Asymptomatic Carotid Surgery Trials
(ACST), 3, 5
Atherosclerotic web on posterior wall of
vessel, 288–289
B
Backbleeding, visual assessment of, 19
Bad ulceration, 86–87
Beaver Dam Eye Study, 7
Benign arteriogram, 86–87
Best medical therapy (BMT), 2
Bifurcation, high, 140–141
Bilateral carotid endarterectomy, 37
Blood pressure monitoring, 66
Blunt needle evacuation technique, 310–311
BMT, see Best medical therapy
Bovine arch and aberrant subclavian
arteries, 62, 64
Bradycardia, 70
C
CA, see Carbonic anhydrase
Carbonic anhydrase (CA), 122
Cardiac function, assessment of, 62–64
Carotid artery, low bifurcation of, 76–77
Carotid artery exposure with retractors,
166–167
Carotid Artery Stenosis with Asymptomatic
Narrowing Operation Versus Aspirin
(CASANOVA) study, 4
Carotid artery stenting (CAS), 3, 42, 57, 126,
388
best outcomes with, 41–43
complications of, 70–71
less favorable studies for, 58–59
medical treatments, comparative study
with, 60, 60
meta-analysis, 60
more favorable studies for, 59–60
randomized clinical trials of, 58
standard procedure of, 69
follow-up of the patients, 70
post-operative monitoring, 70
procedures, 70
settings and monitoring, 69
technical considerations, 66
approach routes, 66
embolic protection methods,
66–67, 67
monitoring, 66
stent selection, 67–68
two-staged angioplasty, 70
techniques for
access routes, 3D-CTA for evaluation
of, 62, 63–64
antiplatelet therapy, 61
cardiac function, assessment of,
62–64
cerebral blood ow (CBF) risk,
evaluation of, 64–65
peri-procedural risk management,
techniques to address, 61
plaque images, 64
Carotid bed, FloSeal for hemostasis in,
328–329
Carotid bruits, 3
Carotid clamping, 354
Carotid cross-clamping, monitoring
techniques during, 18
general anesthesia (GA), monitoring
techniques under
functional evaluations, 22–25
vascular evaluations, 19–22
intra-operative shunting, 27–28
shunt
insertion of, 28–29
need for, 28
working of, 29
Carotid endarterectomy (CEA), 2, 9, 13–14,
36, 40–41, 58, 118, 134, 372, 407
best outcomes with, 41
major nerve structures potentially injured
during, 176–177
MR ndings and intra-operative view
during, 119
other nerves at risk during, 178–181
randomized clinical trials of, 58
thyroid mass found at time of, 174–175
Carotid Guardwire (Medtronic), 66
Carotid kink, 106–107, 398–399
Carotid plaque, deep ulceration of, 84–85
Carotid revascularization, complications of
complications following surgery, 39–40
rationale, 38–39
Carotid risks in non-carotid pre-operative
patients, 6
421
422 INDEX
https://t.me/medicina_free
Carotid sheath
common carotid artery dissection from,
351, 352
four sutures in, 170–171
and internal jugular vein, 347
opening of, 348
scarring, in a case of recurrent stenosis,
402–403
Carotid sinus nerve blockade, 353
Carotid siphon, tandem lesions of, 14
Carotid stenosis
with distal cervical aneurysm, 108–109
endovascular treatment of, 40
carotid artery stenting (CAS), 41–43
carotid endarterectomy (CEA), 41
“high-risk” patients, 43
Carotid ultrasound, 118
CAS, see Carotid artery stenting
CASANOVA study, see Carotid Artery
Stenosis with Asymptomatic
Narrowing Operation Versus Aspirin
study
Catheter entrapment, 64, 65
Catheter insertion, femoral artery pseudo-
aneurysm after, 388–389
CBF, see Cerebral blood ow
CCA, see Cervical carotid artery; Common
carotid artery
CCO, see Contralateral carotid occlusion
CEA, see Carotid endarterectomy
Cerebral blood ow (CBF), 382
evaluation of CBF risk, 64–65
Cerebral circulatory reserve, 120
Cerebral hemodynamics, 120
hyperperfusion syndrome after CEA/
CAS, 123–124
15
O positron emission tomography (PET),
120–122
single photon emission tomography
(SPECT), 122–123
Cerebral hyperperfusion syndrome (CHS),
64
Cerebral perfusion pressure (CPP), 19, 120
Cerebrovascular accident (CVA), 3
Cervical carotid aneurysm associated with
Marfan syndrome, 415–418
Cervical carotid artery (CCA), 78–79
Cervical carotid reconstruction, surgical
technique of, 30, 31–36
indications, 30–31
pre-operative studies and preparation, 31
CHS, see Cerebral hyperperfusion
syndrome
Circumferential fashion, removal of
fragments in, 276–277
Clamp removal sequence at completion of
arteriotomy, 314–315
Clopidogrel, 61
Common carotid artery (CCA), 2, 11, 32, 35,
76, 104, 116, 158, 306, 372, 392
clean edges at both CCA and ICA,
286–287
dissection, from carotid sheath, 351, 352
extensive plaque in, 90–91
rst demonstration of, 162–163
initial placement of, 238–239
long, extensive, 234–235
primary closure in, 366
second limb of repair, 300–301
securing of shunt in, 240–241
sharp scissors transection of CCA plaque,
260–261
sharp transection in, 258–259, 361
shunt in, 236–237
shunt tube insertion into, 357
Common facial vein
jugular vein, 152–153
ligation of, 154–155
secure ligation of, 156–157
Complete carotid occlusion, 37
technique for exploration of, 374–375
Complete post-operative occlusion, 114–115
Complications, 369
aneurysm formation 4 years post-
operatively, 380–381
femoral artery pseudo-aneurysm after
catheter insertion, 388–389
Fogarty catheters to re-open thrombosed
internal carotid artery, 376–377
post-CEA/CAS DWI-positive lesions,
386–387
post-CEA hyperperfusion syndrome,
382–383
post-CEA occlusion of external carotid
artery, 384–385
posterior carotid wall, stab wound of,
370–371
post-operative internal carotid artery
thrombosis, 372–373
post-operative wound hematoma, 378–379
technique for exploration of complete
carotid occlusion, 374–375
Compressed spectral array (CSA), 22–23
Computed tomography angiography
(CTA), 126
Concurrent carotid disease and intra-cranial
aneurysm, 14
Concurrent coronary/carotid disease, 15–16
Contralateral carotid occlusion (CCO),
13–14
Contralateral carotid stenosis, 5–6
Contralateral middle cerebral artery, 98–99
Cooper, Astley, 2
CPP, see Cerebral perfusion pressure
Critical stenosis, 12
CSA, see Compressed spectral array
CTA, see Computed tomography
angiography
CVA, see Cerebrovascular accident
D
DAPT, see Dual antiplatelet therapy
DeBakey clamp, 240, 258
Density-modulated spectral array (DSA), 23
DEPDs, see Distal embolic protective
devices
Diffusion-weighted MRI (DWI), 382
Digastric muscle and hypoglossal nerve,
high bifurcation with
left carotid exposure, 194–195
right carotid exposure, 196–197
Digital subtraction angiography (DSA), 388
Dissection and exposure, ease of, 142–143
Distal cervical aneurysm, carotid stenosis
with, 108–109
Distal embolic protective devices (DEPDs),
59
Distal internal carotid artery, placement of
shunt in, 244–245
Doppler auscultation for extent of plaque,
214–215
Doppler examination of repair, 316–317
Doppler signal, 270–271
Dry repair, surgicel on, 330–331
DSA, see Density-modulated spectral array;
Digital subtraction angiography
Dual antiplatelet therapy (DAPT), 12, 61
Dual layer micromesh (braided) stents, 68
DWI, see Diffusion-weighted MRI
E
ECA, see External carotid artery
ECST, see European Carotid Surgery Trial
EEG, see Electroencephalographic
8-French guiding catheter, 66
Electrocardiogram, 66
Electroencephalographic (EEG), 78
Embolic protection methods, 66–67, 67
Endarterectomy
on opposite side, 360
start of, 359
Endovascular treatment of carotid stenosis,
40
carotid artery stenting (CAS), best
outcomes with, 41–43
carotid endarterectomy (CEA), best
outcomes with, 41
“high-risk” patients, 43
European Carotid Surgery Trial
(ECST), 8
External carotid artery (ECA), 2, 10, 11, 32,
36, 80, 116, 138, 384, 394
dissection, 116–117
opening of
because of poor Doppler signal,
270–271
inadequate feathering, 266–269
repair, 272–273
plaque removal from, 264–265
post-CEA occlusion of, 384–385
repair of
left carotid exposure, 298–299
right carotid exposure, 296–297
sharp transection in, 363
F
Facial vein
common, 349
minor branches of, 158–160
Femoral artery pseudo-aneurysm after
catheter insertion, 388–389
18
F-uorodeoxyglucose (FDG) PET, 120
INDEX 423
https://t.me/medicina_free
FloSeal for hemostasis in carotid bed,
328–329
Focal internal carotid artery ulcer, 82–83
Focal plaque in proximal internal carotid
artery, 232–233
Fogarty catheters, 376–377
Framingham study, 3
G
GA, see General anesthesia
GALA trial, 17
General anesthesia (GA), 16, 18
functional evaluations
EEG monitoring, 22–23
NIRS measurement, 23–25
SSEP monitoring, 23
and skin incision, 344
vascular evaluations
backbleeding, visual assessment of, 19
intra-operative angiography, 21–22
intra-operative Doppler scanning, 22
intra-operative rCBF, 19–20
peri-operative retinal arterial pressure,
21
stump pressure, 19
transcranial Doppler, 20–21
General anesthetics versus regional
anesthetics, 17
Great auricular nerve, 346
H
Hebenstreit, 2
Hemashield patch graft, completed dry
repair without and with, 318–325
Hemashield roof patch, 404
Hemashield roof patch graft, suture
sequence and placement of, 302–305
Hemovac drain, 336–337
Heparinization, 30
History of carotid artery surgery, 2
Hollenhorst plaque, 6–7
Hydroxyl-methyl-glutaryl-CoA
reductase, 3
Hyperperfusion syndrome, 123
after CEA/CAS, 123–124
Hypoglossal nerve, 190–191, 350
Hypotension, 70
I
ICA, see Internal carotid artery
ICA, see Ipsilateral carotid artery
ICG videoangiography, see Indocyanine
green videoangiography
ICH, see Intra-cerebral hemorrhage
I-IMP SPECT, 122, 122
ILT, see Intra-luminal thrombus
IMT, see Intima-media thickness
“Inaccessible” siphon disease, 14
Incisions
along common and internal carotid
arteries, 224–225, 355
alternate, 136–137
draped and ready for, 144–145
for high bifurcation, 140–141
Indocyanine green (ICG) videoangiography,
352, 384
Inamed plaque invasion into media and
adventitia, 411–414
Internal carotid artery (ICA), 2, 11, 32–33
35, 76, 104, 136, 138, 372
bleeding and evacuation of shunt before
placement in, 242–243
clean edges at both CCA and ICA,
286–287
Hemashield patch, 274–275
opened at exploration, 172–173
plaque, 208–209, 234–235
plaque removal from, 262–263
primary closure in, 365
repair beginning in, 290–291
securing of shunt in, 248–249
sharp transection in, 362
shunt in, 236–237
single posterior tacking suture, 284–285
“stump” treatment in, 394–397
suture sequence and placement of
Hemashield roof patch graft on,
302–305
tacking sutures placement in, 282–283,
364
Internal carotid stump, 104–105
Internal shunt tube, removal of, 367
Intima-media thickness (IMT), 118
Intra-cerebral hemorrhage (ICH), 9
Intra-cranial aneurysm, 14
Intra-luminal thrombus (ILT), 12–13,
110–111
Intra-operative angiography, 21–22
Intra-operative Doppler scanning, 22
Intra-operative regional cerebral blood ow,
19–20
Intra-plaque hemorrhage, 407
Intravenous thrombolysis (IVT), 10
“Inverse steal” effect, 18
Ipsilateral carotid artery (ICA), 92, 110
Isolated common carotid artery stenosis,
treatment of, 392–393
IVT, see Intravenous thrombolysis
,
J
Javid clamp, 306
around internal carotid artery, 218–219
Jugular vein
common facial vein, 152–153
external, 148–149
internal, 347
L
Large left carotid kink, repair and
straightening of, 398–399
Left carotid artery stenosis, 125, 126
Left carotid endarterectomy, 278–279
Left carotid exposure, 280–281
Lesion with 95% stenosis, 88–89
Local/regional anesthesia, 16–18
Loftus clamp, 306
Loftus shunt, 236
Loftus shunt clamps, 220–221
Loftus-type carotid shunt in place, 250–251
M
MACE, see Major adverse cardiovascular
events; Mayo Asymptomatic Carotid
Endarterectomy Trial
Magnetization-prepared rapid acquisition
with gradient echo (MPRAGE), 119
Major adverse cardiovascular events
(MACE), 13
Marfan syndrome, 415–418
Massachusetts General Hospital, 9
Matched hypo-metabolism, 123
Mayo Asymptomatic Carotid
Endarterectomy Trial (MACE), 4
MCA, see Middle cerebral artery
MCAV, see Middle cerebral artery velocities
Median power frequency (MPF), 23
MESs, see Microembolic signals
Metzenbaum Scissors, 402
MI, see Myocardial infarction
Michel clips, 334
platysma with, 146–147
Microembolic signals (MESs), 66
Microscopic internal carotid artery repair,
294–295
Micro-surgical endarterectomy, 36–37
Middle cerebral artery (MCA), 20
Middle cerebral artery velocities (MCAV),
20
Mild carotid stenosis with repeated stroke,
407–410
Mo.Ma (Medtronic), 67
MPF, see Median power frequency
MPRAGE, see Magnetization-prepared
rapid acquisition with gradient echo
Myocardial infarction (MI), 3
Myointimal hyperplasia, 400–401
N
NASCET, see North American Symptomatic
Carotid Endarterectomy Trial
Near-infrared spectroscopy (NIRS), 66
Neurological decit, acute, 9–10
NIRS, see Near-infrared spectroscopy
Non-carotid pre-operative patients, carotid
risks in, 6
Non-invasive MRA and CTA for surgical
planning, 124–128
North American Symptomatic Carotid
Endarterectomy Trial (NASCET), 7,
8, 9, 12, 16, 41
“No touch” technique for Prolene suture,
292–293
O
Occluded internal carotid artery, “stump”
treatment in, 394–397
OEF, see Oxygen extraction fraction
424 INDEX
https://t.me/medicina_free
Omohyoid
isolation of, 184–185
retracted, 186–187
Omohyoid muscle
division of, 188–189
low bifurcation with, 182–183
Operative eld, nal view of, 368
15
O positron emission tomography (PET),
120–122
Oxygen extraction fraction (OEF), 120
P
P2Y12 response units (PRU), 61
Parotid gland, dissection behind, 160–161
Patch grafting, 29
Patch repair, four rip-stop free sutures in,
312–313
Peak power frequency (PPF), 23
Peneld retractor, false plane demonstrated
with, 230–231
Peri-operative retinal arterial pressure, 21
Peri-procedural risk management,
techniques to address,
Pilz, 2
Plaque
Doppler auscultation for extent of,
214–215
extensive plaque erosion into adventitial
layer, 216–217
images, 64
internal carotid artery (ICA) plaque,
208–209
MRI, 118–120
removal
from external carotid artery, 264–265
at lateral edge, 256–257
tactile and visual end of
left carotid exposure, 210–211
right carotid exposure, 212–213
Plaque content, observation of, 358
Plaque ulceration and stroke risk markers,
12
Platysma, closure of, 334–335
Platysma incision, 345
Platysma with Michel clips, 146–147
Polytetraouroethylene (PTFE) patches, 29
Post-CEA/CAS DWI-positive lesions,
386–387
Post-CEA hyperperfusion syndrome,
382–383
Post-CEA occlusion of external carotid
artery, 384–385
Post-dilatation, 70
Posterior carotid wall, stab wound of,
370–371
Post-operative considerations, 38
Post-operative hyperperfusion, 123
Post-operative internal carotid artery
thrombosis, 372–373
Post-operative wound hematoma, 378–379
Potts Scissors, 33
Potts Scissors opening, 226–227
Potts Scissors opening vessel, 228–229
PPF, see Peak power frequency
61
Pre-dilatation, 70
Pre-operative external carotid artery
occlusion, 102–103
Prolene suture, “no touch” technique for,
292–293
Proximal internal carotid artery, focal
plaque in, 232–233
PRU, see P2Y12 response units
Pseudotandem stenosis, 14
PTFE patches, see Polytetraouroethylene
patches
R
RA, see Regional anesthesia
Radiographic studies, 75
ascending pharyngeal artery, X-ray
identication of, 94–95
benign arteriogram, 86–87
carotid artery, low bifurcation of, 76–77
carotid kink,
carotid plaque, deep ulceration of, 84–85
cerebral hemodynamics, 120
hyperperfusion syndrome after CEA/
15
O positron emission tomography
single photon emission tomography
cervical carotid artery (CCA), high
common carotid artery (CCA), extensive
complication
complete post-operative occlusion,
external carotid artery dissection,
suture line, clot along, 112–113
contralateral middle cerebral artery, cross
distal cervical aneurysm, carotid stenosis
focal internal carotid artery ulcer, 82–83
internal carotid stump, 104–105
intra-luminal thrombus, 110–111
lesion with 95% stenosis, 88–89
morphology and plaque content, 118
carotid ultrasound, 118
18
F-uorodeoxyglucose (FDG) PET, 120
plaque MRI, 118–120
non-invasive MRA and CTA for surgical
pre-operative external carotid artery
shunting, need for, 100–101
side-by-side carotid artery positioning,
string sign, 92–93
tandem stenosis, 96–97
rCBF, see Regional cerebral blood ow
Recent stroke, special considerations with,
Reconstruction of carotid, 1
acute stroke, 37
106–107
CAS, 123–124
(PET), 120–122
(SPECT), 122–123
bifurcation of, 78–79
plaque in, 90–91
114–115
116–117
lling into, 98–99
with, 108–109
planning, 124–128
occlusion, 102–103
80–81
11
bilateral carotid endarterectomy, 37
complete occlusion, 37
complications of carotid revascularization
following surgery, 39–40
rationale, 38–39
endovascular treatment of carotid
stenosis, 40
best outcomes with CAS, 41–43
best outcomes with CEA, 41
“high-risk” patients, 43
history, 2
micro-surgical endarterectomy, 36–37
post-operative considerations, 38
scientic foundation for carotid artery
treatments, 2
asymptomatic carotid disease, 3–7
best medical therapy, 3
clinical evaluation, 11–12
special surgical considerations, 12–16
symptomatic carotid disease, 7–11
surgical technique of cervical carotid
reconstruction, 30
indications, 30–31
pre-operative studies and preparation,
31
surgical technique, 31–36
technical considerations
anesthesia, 16–18
arteriotomy techniques, 29–30
monitoring techniques during carotid
cross-clamping, 18–29
Recurrent carotid stenosis, 14–15
Recurrent stenosis, scarring in carotid
sheath in a case of, 402–403
Regional anesthesia (RA),
16
Regional cerebral blood ow (rCBF), 18,
19–20
Retractors, carotid artery exposure with,
166–167
Reversible ischemic neurologic decit
(RIND), 11, 28
Right carotid exposure, 308–309
RIND, see Reversible ischemic neurologic
decit
Ring clamp and blunt sh-hook retraction
for total carotid exposure, 168–169
Rummel tourniquet, 164–165, 240
placement of cross-clamp below,
222–223
S
Saphenous vein patch graft, placement of,
340–341
Saphenous vein roof patch, 404–406
SAPPHIRE trial, 39, 42, 59
Schneider Wallstent trial, 42
Scientic foundation for carotid artery
treatments, 2
asymptomatic carotid disease, 3
asymptomatic bruit, 3–5
contralateral carotid stenosis, 5–6
Hollenhorst plaque, 6–7
non-carotid pre-operative patients,
carotid risks in, 6
INDEX 425
https://t.me/medicina_free
best medical therapy, 3
clinical evaluation, 11–12
special surgical considerations
concurrent carotid disease and intra-
cranial aneurysm, 14
concurrent coronary/carotid disease,
15–16
contralateral carotid occlusion (CCO),
13–14
critical stenosis, 12
intra-luminal thrombus (ILT), 12–13
plaque ulceration and stroke risk
markers, 12
recurrent carotid stenosis, 14–15
tandem lesions of the carotid siphon,
14
symptomatic carotid disease, 7
acute neurological decit, 9–10
recent stroke, special considerations
with, 11
stump syndromes, 11
subacute complete carotid occlusion, 10
transient ischemic attacks, 8–9
Self-expanding stents, 67
Shaggy aorta, 62, 63
Sharp transection
in common carotid artery, 361
in external carotid artery, 363
in internal carotid artery, 362
Sheath, closure of, 332–333
Shunt
insertion of, 28–29
need for, 28, 100–101
removal of, 306–307
working of, 29
Shunt down common carotid artery, initial
placement of, 238–239
Shunt function, evaluation of, 252–253
Shunt placement
in distal internal carotid artery, 244–245
potential for intimal damage from,
246–247
repair with shunt in place, 254–255
Shunt tube insertion
into common carotid artery, 357
into internal carotid arter, 356
Side-by-side carotid anatomy, 198–199
Side-by-side carotid artery positioning,
80–81
Side-by-side carotid exposure, 138–139
Single photon emission tomography
(SPECT), 122–123
6-French guiding sheath, 66
Skin and Hemovac drain, 336–337
Skin closure, 338–339
Skin incision, general anesthesia and, 344
SNACC, see Society of Neuroanesthesia and
Critical Care
Society of Neuroanesthesia and Critical
Care (SNACC), 16
SPARCL trial subgroup analysis, 3
SPECT, see Single photon emission
tomography
Stab wound of posterior carotid wall,
370–371
Staged angioplasty, 71, 71
STA pulse, see Supercial temporal artery
pulse
Stenosis, rapid recurrence of, 400–401
Stent selection, 67–68
Sternocleidomastoid muscle, 150–151
and great auricular nerve, 346
Sternomastoid artery, 192–193
String sign, 92–93
Stroke, 11
acute, 37
mild carotid stenosis with repeated
stroke, 407–410
Stroke risk markers, 12
Stump pressure, 19
Stump syndromes, 2, 11, 394–397
Subacute complete carotid occlusion, 10
Supercial temporal artery (STA) pulse, 38
Superior thyroid artery, isolation of
left carotid exposure, 202–203
right carotid exposure, 200–201
Surgical instruments, 132–133
Surgical positioning, 134–135
Surgical technique, 131, 343
air, evacuation of, 308–309
alternate incisions, 136–137
ascending pharyngeal artery, isolation of
left, 204–205
right, 206–207
atherosclerotic web on posterior wall of
vessel, 288–289
blunt needle evacuation technique,
310–311
carotid artery exposure with retractors,
166–167
carotid clamping, 354
carotid endarterectomy
major nerve structures potentially
injured during, 176–177
other nerves at risk during, 178–181
carotid sheath
dissection of common carotid artery
from, 351, 352
four sutures in, 170–171
and internal jugular vein, 347
opening of, 348
carotid sinus nerve blockade, 353
circumferential fashion, removal of
fragments in, 276–277
clamp removal sequence at completion of
arteriotomy, 314–315
common and internal carotid arteries,
incision along, 355
common carotid artery (CCA)
clean edges at both CCA and ICA,
286–287
rst CCA control with 0 silk tie and
Rummel tourniquet, 164–165
rst demonstration of, 162–163
long, extensive, 234–235
primary closure in, 366
second limb of repair, 300–301
securing of shunt in, 240–241
sharp scissors transection of CCA
plaque, 260–261
sharp transection in, 258–259
shunt in, 236–237
common facial vein, 349
jugular vein, 152–153
ligation of, 154–155
secure ligation of, 156–157
completed removal, sharp margin
left carotid endarterectomy, 278–279
left carotid exposure, 280–281
digastric muscle and hypoglossal nerve,
high bifurcation with
left carotid exposure, 194–195
right carotid exposure, 196–197
dissection and exposure, ease of, 142–143
distal internal carotid artery, placement of
shunt in, 244–245
Doppler auscultation for extent of plaque,
214–215
Doppler examination of repair, 316–317
draped and ready for incision, 144–145
dry repair, surgicel on, 330–331
endarterectomy, start of, 359
endarterectomy on the opposite side, 360
extensive plaque erosion into adventitial
layer, 216–217
external carotid artery, opening of
because of poor Doppler signal,
270–271
inadequate feathering, 266–269
repair, 272–273
external carotid artery, plaque removal
from, 264–265
external carotid artery, repair of
left carotid exposure, 298–299
right carotid exposure, 296–297
external jugular vein, 148–149
facial vein, minor branches of, 158–160
FloSeal for hemostasis in carotid bed,
328–329
general anesthesia and skin incision, 344
Hemashield patch graft, completed dry
repair without and with, 318–325
high bifurcation, incision for, 140–141
hypoglossal nerve, 190–191
hypoglossal nerve, 350
incision along common and internal
carotid arteries, 224–225
internal carotid artery (ICA)
bleeding and evacuation of shunt
before placement in, 242–243
clean edges at both CCA and ICA,
286–287
Hemashield patch, 274–275
placement of tacking sutures in,
282–283
plaque, 208–209, 234–235
plaque removal from, 262–263
primary closure in, 365
repair beginning in, 290–291
securing of shunt in, 248–249
shunt in, 236–237
single posterior tacking suture, 284–285
suture sequence and placement of
Hemashield roof patch graft on,
302–305
Соседние файлы в папке Библиотека им академика М.И. Перельмана