TWilliam2019
Guru
35301 & 34001
Description of procedure and findings: After informed consent, the patient was taken to the operating room and placed in the supine position. Pt was sedated and intubated and general endotracheal anesthesia was administered. The patient was positioned with the neck slightly hyperextended and the head rotated toward the contralateral side. The left face, neck and chest were prepped and the patient was draped in the usual sterile fashion. Exposed skin was covered with an iodine-impregnated adhesive drape. Proper time out performed and agreed upon by all parties present. Antibiotics addressed. An incision was made along the anterior border of the sternocleidomastoid muscle. Sharp dissection and electrocautery were used to divide the soft tissue and fat. Dissection was carried through the platysma muscle and then continued along the anterior border of the sternocleidomastoid muscle until the internal jugular vein was identified. The facial vein was identified and ligated and divided and the jugular vein was retracted laterally. The common carotid artery was identified and was dissected free proximally until a normal healthy disease-free portion of the common carotid was identified. The common carotid artery was then dissected free circumferentially in this location and was looped with a silastic loop. Dissection then continued distally to the carotid bifurcation. The superior thyroid and external carotid arteries were dissected free circumferentially and doubly looped with silastic vessel loops. Dissection then continued distally along the internal carotid artery until a normal healthy disease-free segment of internal carotid artery was identified. The internal carotid artery was then dissected free circumferentially in this location and was looped with a silastic vessel loop. The hypoglossal nerve was identified and protected during this portion of the dissection. At this point, the patient's blood pressure was brought up to around 160 systolic and was maintained at this level during carotid artery occlusion. The patient was administered a heparin dosed based on baseline ACT. ACT ensured to be >250 prior to clamping. ACT was maintained greater than 250 for the remainder of the procedure. Of note, based on preoperative CTA head and neck the thrombus is located in the distal common carotid artery. At this point, the internal carotid artery was occluded with vessel loop. The the external carotid and superior thyroid arteries were controlled with vessels loops. An arteriotomy was then made in the common carotid artery with a number 11 scalpel blade and modified proximally and distally with Pott's scissors. Digital control on the proximal common carotid artery was maintained initially and common carotid artery was allowed to forward bleed to expel any loose thrombus. While maintaining control on the proximal carotid artery, a #4 Fogarty was guided proximally into the common carotid artery and insufflated and slowly pulled back several times to expel the remaining thrombus until no further thrombus was noted. At this point, I could see a more proximal ulcerative plaque in which the potts scissors were used to extent the arteriotomy. Arteriotomy continued until a healthy disease-free lumen of the internal and common carotid artery was identified. There appeared to be a focal web in the proximal internal carotid artery. The ICA was briefly unclamped and excellent back-bleeding was noted. The ICA was re-occluded. A #8shunt was carefully guided into the internal and common carotid artery. An endarterectomy plane was then developed between the inner and middle layers of the media in the common carotid artery. Endarterectomy continued circumferentially across the CCA and the plaque was divided sharply. Endarterectomy continued distally to the carotid bifurcation. A modified eversion technique was used to endarterectomize the external carotid artery with good results. Endarterectomy then continued distally in the internal carotid artery until the plaque feathered free smoothly. There was no intimal flap or abrupt step-off at the distal end-point. The luminal surface was then irrigated with Heparinized saline and all debris was removed. The luminal surface was then again copiously irrigated with heparinized saline. There were no loose intimal flaps, no loose debris and no plaque remaining. The arteriotomy was then closed with a patch angioplasty technique using a bovine pericardial patch and a running prolene suture in a running fashion. Prior to completion of closure of the arteriotomy, the shunt was clamped and removed. The ICA and ECA were backbled. The ICA and ECA were then briefly unclamped and allowed to back-bleed.The CCA was forward bled. There was good back-bleeding without thrombus. Flow was restored to the external carotid artery first. After several cardiac cycles flow was restored to the internal carotid artery.
Intra-operative carotid artery duplex was then performed.
Ultrasonographic findings: Using B-mode grey-scale ultrasound, the common, internal and external carotid arteries exhibit normal intra-luminal appearance with no loose debris, no loose intimal flaps and no abnormal intra-luminal echo-densities. There is excellent antegrade waveform in the common, external and internal carotid arteries by arterial duplex without evidence of hemodynamically significant stenosis. At this point, it was felt that excellent technical results had been obtained.
The patient was administered Protamine to reverse the systemic effects of the Heparin. Blood pressure was allowed to return to a normal physiologic range. Following this, the incision was copiously irrigated with normal saline. Thrombin gel foam placed in the incision and light pressure was held with a dry sponge until hemostasis achieved. Excess gel foam removed. The incision was again copiously irrigated and suctioned and excellent hemostasis was observed. A #15 Jackson Pratt drain was placed through a separate small incision and placed in the wound. The incision was then closed in layers with 3-0 vicryl used to re-approximate the sternocleidomastoid muscle with the cervical fascia and platysma muscle layer. The skin was closed with a subcuticular monocryl suture. Dermabond was applied.
Description of procedure and findings: After informed consent, the patient was taken to the operating room and placed in the supine position. Pt was sedated and intubated and general endotracheal anesthesia was administered. The patient was positioned with the neck slightly hyperextended and the head rotated toward the contralateral side. The left face, neck and chest were prepped and the patient was draped in the usual sterile fashion. Exposed skin was covered with an iodine-impregnated adhesive drape. Proper time out performed and agreed upon by all parties present. Antibiotics addressed. An incision was made along the anterior border of the sternocleidomastoid muscle. Sharp dissection and electrocautery were used to divide the soft tissue and fat. Dissection was carried through the platysma muscle and then continued along the anterior border of the sternocleidomastoid muscle until the internal jugular vein was identified. The facial vein was identified and ligated and divided and the jugular vein was retracted laterally. The common carotid artery was identified and was dissected free proximally until a normal healthy disease-free portion of the common carotid was identified. The common carotid artery was then dissected free circumferentially in this location and was looped with a silastic loop. Dissection then continued distally to the carotid bifurcation. The superior thyroid and external carotid arteries were dissected free circumferentially and doubly looped with silastic vessel loops. Dissection then continued distally along the internal carotid artery until a normal healthy disease-free segment of internal carotid artery was identified. The internal carotid artery was then dissected free circumferentially in this location and was looped with a silastic vessel loop. The hypoglossal nerve was identified and protected during this portion of the dissection. At this point, the patient's blood pressure was brought up to around 160 systolic and was maintained at this level during carotid artery occlusion. The patient was administered a heparin dosed based on baseline ACT. ACT ensured to be >250 prior to clamping. ACT was maintained greater than 250 for the remainder of the procedure. Of note, based on preoperative CTA head and neck the thrombus is located in the distal common carotid artery. At this point, the internal carotid artery was occluded with vessel loop. The the external carotid and superior thyroid arteries were controlled with vessels loops. An arteriotomy was then made in the common carotid artery with a number 11 scalpel blade and modified proximally and distally with Pott's scissors. Digital control on the proximal common carotid artery was maintained initially and common carotid artery was allowed to forward bleed to expel any loose thrombus. While maintaining control on the proximal carotid artery, a #4 Fogarty was guided proximally into the common carotid artery and insufflated and slowly pulled back several times to expel the remaining thrombus until no further thrombus was noted. At this point, I could see a more proximal ulcerative plaque in which the potts scissors were used to extent the arteriotomy. Arteriotomy continued until a healthy disease-free lumen of the internal and common carotid artery was identified. There appeared to be a focal web in the proximal internal carotid artery. The ICA was briefly unclamped and excellent back-bleeding was noted. The ICA was re-occluded. A #8shunt was carefully guided into the internal and common carotid artery. An endarterectomy plane was then developed between the inner and middle layers of the media in the common carotid artery. Endarterectomy continued circumferentially across the CCA and the plaque was divided sharply. Endarterectomy continued distally to the carotid bifurcation. A modified eversion technique was used to endarterectomize the external carotid artery with good results. Endarterectomy then continued distally in the internal carotid artery until the plaque feathered free smoothly. There was no intimal flap or abrupt step-off at the distal end-point. The luminal surface was then irrigated with Heparinized saline and all debris was removed. The luminal surface was then again copiously irrigated with heparinized saline. There were no loose intimal flaps, no loose debris and no plaque remaining. The arteriotomy was then closed with a patch angioplasty technique using a bovine pericardial patch and a running prolene suture in a running fashion. Prior to completion of closure of the arteriotomy, the shunt was clamped and removed. The ICA and ECA were backbled. The ICA and ECA were then briefly unclamped and allowed to back-bleed.The CCA was forward bled. There was good back-bleeding without thrombus. Flow was restored to the external carotid artery first. After several cardiac cycles flow was restored to the internal carotid artery.
Intra-operative carotid artery duplex was then performed.
Ultrasonographic findings: Using B-mode grey-scale ultrasound, the common, internal and external carotid arteries exhibit normal intra-luminal appearance with no loose debris, no loose intimal flaps and no abnormal intra-luminal echo-densities. There is excellent antegrade waveform in the common, external and internal carotid arteries by arterial duplex without evidence of hemodynamically significant stenosis. At this point, it was felt that excellent technical results had been obtained.
The patient was administered Protamine to reverse the systemic effects of the Heparin. Blood pressure was allowed to return to a normal physiologic range. Following this, the incision was copiously irrigated with normal saline. Thrombin gel foam placed in the incision and light pressure was held with a dry sponge until hemostasis achieved. Excess gel foam removed. The incision was again copiously irrigated and suctioned and excellent hemostasis was observed. A #15 Jackson Pratt drain was placed through a separate small incision and placed in the wound. The incision was then closed in layers with 3-0 vicryl used to re-approximate the sternocleidomastoid muscle with the cervical fascia and platysma muscle layer. The skin was closed with a subcuticular monocryl suture. Dermabond was applied.