Dolichoarteriopathy – Severe kinking with luminal narrowing type I/III of the right internal carotid artery - vascular surgery
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Right cervical access
Dissecting the common carotid artery
Dissecting the internal and external carotid arteries
Carefully mobilize the ICA and ECA in no-touch technique and then encircle the ECA with a surgical vessel loop.
1. The hypoglossal nerve lies at the upper aspect inferior to the lower jaw, the deep ansa cervicalis leads directly to it. Exposure of the hypoglossal nerve is facilitated if the ansa cervicalis is medialized first.
2. After shortening the ICA, it must be reinserted in a slight curve, but still straightened. Thus, the ICA must be dissected far craniad to prevent subsequent kinking after reinsertion.
Clamping the carotid arteries and transecting the ICA
After systemic heparinization (5000 IU) and waiting out the circulation time, clamp the supraaortic branches: ICA, CCA and then ECA.
Transect the ICA right at its origin from the CCA with a scalpel or Potts scissors and extend the arteriotomy at the carotid bifurcation. To prepare for shortening and reinserting the ICA, extend the arteriotomy, including the ICA, lengthwise up to the level of the resection line.
When operating in general anesthesia, temporarily insert a shunt between CCA and ICA to maintain perfusion if the procedure takes longer than 15–20 minutes before the blood flow is released. In general anesthesia intraoperative neuromonitoring is also recommended.
If surgery is performed with cervical plexus block, as demonstrated in the video example, intraoperative neuromonitoring is not required. Instead, the patient is handed a "squeaky ball" which he/she must squeeze intermittently when prompted to do so (e.g., when the carotid arteries are clamped).
Shortening and reinserting the ICA
Flushing ICA and CCA, intraoperative quality assurance angiography
Valsalva maneuver to check for bleeding
Redon drain, wound closure