do not use cerebrospinal uid drainage on routine basis. Bilateral ultrasound-guided percutaneous access with use of preclose Perclose ProGlide sys­tem technique is applied for the main device deliv­ery. If ilio-femoral dissection is present, preferentially the non-dissected side is used for the device deployment. For initial vascular access, a Bentson wire (Boston Scientic, Marlborough, MA, USA) with 100 cm Pig tail catheter (Cook Medical) support is advance to ascending aorta with subsequent exchange for a 300 cm double curve Lunderquist® extra-stiff wire (Cook Medical). Contralateral diagnostic Pigtail catheter is advanced in a similar fashion and positioned in the ascending aorta. Femoral venous access is rou­tinely established for temporary percutaneous pac­ing wires that are placed in the right ventricle. They are used for rapid cardiac pacing during stent deployment and during aortic angioplasty with rate set to 180 to 200bpm. In the next step, aortic arch angiogram is performed and using informa­tion from the preoperative CTA, intraoperative conrmation of the position of arch vessels is made and nal level of the proximal deployment of the rst stent is selected. In cases where L SCA is involved and when GORE Thoracic Branch Endograft (TBE) is used, we obtain additional through and through wire access from the left wrist and out of the large sheath of the main device delivery as per Gore device IFU.In all other cases, our to go to device is Zenith TX2 when deployed into the native aorta or Zenith Alpha (Cook Medical) covered stents when deployment is into preexisting Dacron graft of either ascending aortic repair or an elephant trunk repair. For all cases requiring left SCA coverage that do not meet ana­tomic criteria for TBE, we perform carotid -to­subclavian bypass usually a day or two prior to the aortic stenting procedure.

Once proximal stent graft is in place, we continue to deploy covered stents to the level just proximal to celiac trunk. We do that to assure that all secondary tears of the aortic dissection ap are excluded as dis­tally as possible. In our experience, this prevents ongoing false lumen ow that may lead to early repair failure. Once all covered stents are in place, we proceed with Zenith Dissection uncovered stents

deployment in the remaining abdominal aorta all the way to the level of iliac bifurcation. At this point for those patients that Petticoat approach is intended, this completes the procedure.

We routinely employ wire protection of all aortic branch vessels that come off the false lumen during aortic angioplasty (Fig.21.9).

exposed rst. Some of the tributaries of IJV will need ligation. Middle thyroid vein in the lower part of the neck and facial vein is generally at the level of carotid bifurcation. If nerves are seen coursing anterior to the carotid artery, the most common being Ansa cervicalis, gentle dissec­tion, and retraction are preferable to transection. Occasionally, the recurrent laryngeal nerve may course across the common carotid (nonrecurrent recurrent laryngeal nerve). The common carotid artery (CCA) is dissected rst and controlled with vessel loop. Keeping close to CCA, the dis­section proceeds cephalad, external carotid artery (ECA), and the very rst branch of it, superior thyroid is controlled with vessel loops. Care should be taken to avoid dissection or rough manipulation of the carotid bulb, since this is the area of disease and rough handling, can cause embolization of atheromatous debris. The inter­nal carotid artery (ICA) beyond the plaque should be dissected and controlled. Enough length of internal carotid should be dissected in case shunt is needed. It is important to identify the hypoglossal nerve which runs obliquely from lateral to medial about two inches cephalad to carotid bifurcation, however it can be lower. Once CCA, ECA, and ICA controlled, the patient is heparinized, adequacy of heparinization moni­tored with activated clotting time (ACT) which should be between 230 and 270 sec. ICA is clamped rst followed by ECA and CCA.Arteriotomy begins in healthy CCA below the diseased area and is extended into the bulb on a slightly lateral location (arteriotomy too medial on the bulb may result in distortion of the bulb when closed and extended anteriorly in ICA beyond the plaque). Endarterectomy is begun after developing an appropriate plane (ideally between the inner and outer media). The entire plaque is removed. The arteriotomy should extend beyond the ending of endarterectomy. No part of the plaque should be left behind (com­plete endarterectomy), particularly on the inter­nal carotid. If there is an intimal ledge, anchoring sutures may be used to tack the area to avoid dis­section when ow is restored. Endarterectomy from ECA is done by eversion technique. All the debris, shards, and bers are removed until the

1. Bleeding: Bleeding can happen after any operative procedure. When happens after CEA, it can have catastrophic consequences. Even moderate hematoma in the neck can cause venous compression, which results in laryngeal edema manifested initially by hoarseness and stridor soon after. This is a surgical emergency. It is important to remove the neck staples/sutures and sutures of the underlying layer to decompress the hematoma by bedside in PACU while preparations are made to return to OR.As soon as the hema­toma is evacuated and the neck decompressed, patient will immediately feel better. The grave mistake is to attempt intubation of a patient in respiratory distress and stridor. Because of the laryngeal edema, the entrance to trachea will be pinhole, the anesthesiologist will not be able to intubate and aggressive attempts to intubate without rst decompressing the neck will result in increasing anxiety on part of the patient, further anoxia and cardiac arrest.

4. Nerve injury: Both cranial and other nerve injuries can happen in carotid operations4. The hypoglossal, vagus, and glossopharyn­geal nerves are in close proximity to the artery. The recurrent laryngeal nerve is the most common to be injured. This can happen by excessive stretch by self-retaining retrac­tors, or direct injury can occur by electrocau­tery, or transection during dissection CCA and ECA.Hoarseness and difculty swallow­ing saliva can occur if there is paralysis of ipsilateral vocal cord. This is very disabling in addition to medicolegal implications. Otolaryngology consult should be sought early for proper evaluation of extent of dis­ability and for intervention. Minor recurrent laryngeal nerve trauma will recover in a few weeks. The other nerve prone to injury is hypoglossal nerve which crosses from lateral to medial side. In most cases, it is about an inch or two higher cephalad to the carotid bifurcation. In some, it can cross lower, closer to carotid bifurcation. Transection can result in tongue deviated to the side of injury and affects the movement of tongue and ability to chew the food. Bilateral hypoglossal nerve injury results in paralysis of the tongue, caus­ing obstruction of oropharyngeal area. Patient will require tracheostomy. Careful history should be taken in any patient who has had

Carotid endarterectomy has been a time-tested operation for symptomatic carotid disease and in select asymptomatic patients. With meticulous attention to every detail like proper patient selec­tion, appropriate indication, tailoring the type of anesthesia to patient’s medical status, neuromon­itoring, good surgical technique, and postopera­tive care by trained team guided by clinical pathway protocols, this procedure can be per­formed with stroke and death rates of 1% or lower. Acknowledging the vital importance of teamwork and practicing it as a habit has bene­ted patients enormously. This indeed is testa­ment to modern surgery.

Derived from renal lithotripsy, intravascular lithotripsy (IVL) is a novel technique that uses high-energy ultrasound waves to improve plaque modication and vessel compliance (Fig. 21.14) [50]. It uses pulsatile sonic pressure waves that pass through soft tissue and selectively interact strongly with high-density calcium, producing sig­nicant shear stresses that have the ability to frac­ture the calcium. Furthermore, it is designed to modify both intimal and medial calcium across a wide range of vascular applications to increase ves­sel compliance, restore vessel mobility, and pro­vide new versatile treatment options for patients.

The Shockwave Medical Peripheral IVL System (Shockwave Medical, Fremont, CA)