Dolichoarteriopathy – Severe kinking with luminal narrowing type I/III of the right internal carotid artery

After infiltration anesthesia incise the skin along the medial border of the sternocleidomastoid muscle. Transect the subcutis and platysma, then enter the anterior fascia of the neck and open the vascular sheath. Ligate and divide the fascial vein. 

Expose the anterior aspect of the common carotid artery (CCA), which is encircled with a surgical vessel loop as a tourniquet.

Tip:

Carefully spare the vagus nerve between the CCA and internal jugular vein.

Carefully mobilize the ICA and ECA in no-touch technique and then encircle the ECA with a surgical vessel loop.

Tips:

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.

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.

Tip:

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).