Carotid endarterectomy is one of the most common operations for vascular surgeons. The standard approach, anteriorly, requires division of the facial vein, frequently additional small tributaries, and sacrifice of the ansa cervicalis.
The facial vein is not infrequently the cause of bleeding on patients returned to the OR who truly have surgical bleeding. The vagus nerve is not well visualized during the standard approach, unless maneuvers are taken to specifically identify it. Although this approach gives good access to the common carotid artery, and to the external carotid, it requires additional maneuvers in order to gain access to the distal internal carotid artery (ICA), which is located more posterolaterally.
This frequently requires ligation of the vascular bundle around the hypoglossal nerve, which can lead to bleeding if not properly addressed. Visualization of the distal ICA is not ideal with this approach.
An alternative: The retrojugular approach
The surgery is performed with the patient prepped in the same fashion as for standard CEA. Skin incision and initial dissection is identical for standard CEA approach, and is made along the sternocleidomastoid, with division of the platysma.
Dissection is carried out just along the border of the SCM until the carotid sheath is encountered. At this point, the dissection differs. Dissection is continued along the lateral border of the internal jugular vein, which is gently dissected from the surrounding tissue.
There are rarely branches along the lateral or posterior border that require ligation. This area is sharply dissected due to the proximity of nervous structures. The vagus nerve is easily visualized utilizing this approach, and left lateral to the carotid artery. Once a sufficient length of jugular has been mobilized, a blunt whietlander is placed, retracting the vein medially. The Carotid artery is then easily visualized, with a long segment of the ICA easily visible.
The hypoglossal nerve and facial vein are not visualized. The ansa cervicalis is not divided. Standard mobilization of the CCA, ICA, and ECA is then performed. With this approach, the ICA is anterior.
Visualization of the ECA is slightly more limited with this approach, but the proximal ECA and superior thyroidal arteries are easily identified and looped. CEA, either with eversion or standard longitudinal incision, is completed in standard fashion. After completion of the CEA, and confirmation of adequate hemostasis, the IJ is simply allowed to return to its normal position. The wound is then closed in standard fashion.
This approach permits significant exposure to a markedly longer segment of the ICA, without division of additional vascular branches, nor mobilization of nerves. There is slightly less visibility of the ECA, but more than adequate for the necessary vascular control. The approach also has less risk of postoperative bleed, and has been reported to be slightly faster than the anterior approach.
Dr. Harris is division chief, Vascular Surgery, at the State University of New York at Buffalo, and an associate medical editor of Vascular Specialist.