Techniques : Technique
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Technique

Direct closure endarterectomy technique.

 

 

 

81 year-old male with an asymptomatic stenosis of the left internal carotid artery.
 
Atherosclerosis risk factors: non insulin dependent diabetes mellitus; hypercholestrolemia.
 
Brain MRI: No ischemic brain lesion.

 

 

 

 

Left carotid bifurcation MRA.

The left carotid bifurcation has a good diameter.

Longitudinal arteriotomy using a scalpel. The arteriotomy is superficial to harvest the entire plaque and analyse it. It is voluntarily made below the limits of the plaque. This allows easily detaching the plaque without enlarging too much the arteriotomy.

The Rob spatula is inserted between the atheromatous plaque and the healthy arterial wall. The endarterectomy plane is situated at the level of the two external third of the media.

Once initiated the internal endarterectomy plane, the internal detachment is started. It is continued up to the superior extremity of the plaque.

The spatula is then inserted downward…

...to start the external endarterectomy plane.

The detachment is extended upward…

....up to the superior extremity of the arteriotomy.

The arteriotomy is then extended few millimeters, taking advantage of the endarterectomy plane.

The detachment of the plaque at the level of the common carotid artery is completed, to make it circumferential. The Rob spatula is then introduced below to take away the atheromatous plaque from the artery wall.

This allows the section of the plaque with Potts scissors avoiding the risk to tear the posterior arterial wall.

The endarterectomy zone is rinsed with heparinized saline.

The external carotid artery ostium is dissected anteriorly…

...and posteriorly.

The plaque is divided using Potts scissors, at the level of the external carotid artery ostium.

Then the detachment is continued at the internal side of the bulb.

To join the superior extremity of the plaque.

The plaque is then sectioned using microsurgery scissors at its superior extremity, at the junction with the healthy arterial wall.

During this gesture, care should be taken no to harm the arterial wall.

 

The section is continued circumferentially. It is greatly facilitated by towing on the atheromatous plaque.

 

The atheromatous plaque is then removed.

 

The internal carotid artery is purged to remove possible debris and test the quality of the backflow.

 

Residual plaque fragments are resected.

 

Detached media segments situated at the level of the proximal section of the atheromatous plaque are resected using Potts scissors or microsurgery scissors. .

 

The last debris are removed using an heparinized saline-soaked compress.

 

The arteriotomy is extended few millimeters distally without reaching the end of the endarterectomy.

 

This allows a better control of the distal intima.

 

The flap absence is verified by an injection of heparinized saline.

 

Possible flaps are seized with a Cushing hemostat and sectioned using microsurgery scissors.

 

If the distal intima has the tendency to detach, it is tacked by 7/0 monofilament sutures with a 9mm needle...

 

...to obtain a satisfactory result.

 

This is also performed at the level of the external carotid artery ostium...

 

...to obtain a satisfactory result.

 

The same thing is done at the level of the common carotid artery.

 

The arteriotomy is closed using a 6/0 monofilament suture, 11 mm needle, starting by the superior row of the running suture.  

 

Then the inferior row of the running suture is performed.

 

The common carotid artery and the internal carotid artery are purged.

 

The endarterectomy zone is rinsed using heparinized saline.

 

The suture is finished…  

 

....and the two monofilament extremities are knotted.

 

The internal carotid artery is unclamped and reclamped to direct possible air bubbles through the external carotid artery. The external and the common carotid arteries are unclamped simultaneously. Then, after few seconds, the internal carotid is unclamped.

 

Surgical piece.

Completion angiography through venous approach.

 

 

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