After longitudinal incision at the anterior border of the sternocleidomastoid muscle (SCM), the incision was deepened through the platysma and the investing layer of the deep cervical fascia was opened along the anterior border of the SCM. The muscle was mobilized and separated from the underlying vascular sheath by sharp dissection along its medial border. Retracting the SCM posteriorly exposed the carotid sheath, which was opened superior to the omohyoid muscle.
The internal jugular vein was dissected along its medial border and retracted posteriorly together with the SCM. The common facial vein and other medial branches were divided, and the internal jugular vein was mobilized laterally. The ansa hypoglossi was pushed laterally.
The common carotid artery (CCA) was isolated using sharp dissection prior to manipulation of the atherosclerotic bifurcation. The vagus nerve was identified and protected. The external carotid artery (ECA) was isolated just above the bifurcation, followed by the internal carotid artery (ICA). The hypoglossal nerve was identified distally along the ICA.
Once the carotid bifurcation was fully exposed, 5000 IU of unfractionated heparin (UFH) was administered.
According to the latest ESVS carotid and antithrombotic guidelines, there are no specific recommendations regarding intraoperative anticoagulation during carotid cross-clamping. There is a recommendation for the use of Unfractionated Heparin or Bivalirudin during open and endovascular arterial procedures, based on expert consensus and one meta-analysis of small observational trials.
Source: Twine CP, Kakkos SK, Aboyans V, Baumgartner I, Behrendt CA, Bellmunt-Montoya S, et al. Editor’s Choice – European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on Antithrombotic Therapy for Vascular Diseases. Eur J Vasc Endovasc Surg. 2023;65(5):627–689.
After UFH administration, the CCA, ECA, and ICA were clamped. There were no significant drops in motor and somatosensory evoked potentials during a 3-minute test period of carotid cross-clamping; therefore, the surgeon decided not to use a shunt during carotid endarterectomy (CEA).
A longitudinal arteriotomy was performed, and using fine dissectors, the optimal plane between the inner and outer medial layers was entered. The distal intima of the ICA was secured with three 6-0 Prolene sutures. Bovine pericardium was used to close the arteriotomy.
The intraoperative course was uneventful, and the patient was transferred to the intensive care unit (ICU) for postoperative monitoring.
