Vascular

Carotid Endarterectomy (Open)

OPERATION: Carotid Endarterectomy (Open)
ANAESTHETIC: General / local anaesthesia
ANTIBIOTICS: As per local policy
POSITION: Supine, head-up, neck extended and rotated to the contralateral side. Ring support under head. Draping from angle of jaw to chin.

INDICATION:
TIA or recent stroke with 70% or greater stenosis of the internal carotid artery on the symptomatic side. Surgery performed as soon as possible after index symptoms, ideally within 48 hours and certainly within 2 weeks. Preoperative imaging: duplex USS and MRA confirming [degree] stenosis.

PROCEDURE:
WHO Checklist performed. Landmarks marked. Neck prepared and draped.

ACCESS:
Longitudinal incision anterior to the sternocleidomastoid muscle. Platysma divided. Internal jugular vein and sternocleidomastoid retracted laterally to expose the carotid sheath. Anterior facial vein doubly ligated and divided. Omohyoid retracted or divided. Common, internal, and external carotid arteries carefully dissected. Carotid body handled with minimal manipulation to prevent haemodynamic instability. Hypoglossal nerve identified crossing the carotid bifurcation and protected throughout. Ansa cervicalis divided if required for exposure.

VASCULAR CONTROL AND SHUNTING:
Heparin 5000 IU administered intravenously. Vascular slings applied to the common, internal, external carotid, and superior thyroid arteries. Arteries clamped in sequence commencing with the internal carotid. Arteriotomy made over the bifurcation and extended cephalad into the internal carotid with Potts scissors. Pruitt-Inahara shunt inserted with proximal blue balloon in the common carotid and distal white balloon in the internal carotid.