Pre-op

Ensure that the patient gets full dose aspirin (325 mg.) the day of surgery. If the patient was on a heparin drip due to actively unstable plaque, then this should be confirmed to be off personally in the preop bay.  The patient should void prior to coming into the OR. No foley.

Nasal intubation is considered for high bifurcations (high C3 or C2) or high ICA plaque mid C2. Oral intubation performed for most cases.  Make sure tube is secured contralateral side of the mouth to the CEA side.

Know what the patient's pre-induction systolic blood pressure is. Usually, you will ask anesthesia to keep their intraoperative blood pressure within the range of the pre-induction SBP. 

Monitoring

SSEPs and EEG.

Positioning

The patient is turned 180 degrees away from anesthesia and both arms are tucked. The neck is rotated very slightly away (~10 degrees) from the surgical site.  A transverse blanket is placed behind the shoulders to achieve mild neck extension.  The ipsilateral shoulder should be at the edge of the bed and the head should be at the top edge of the bed.  No Foley placement.

Marking

Facial hair should be shaved at least 1cm around planned incision. The sternal notch and the angle of the mandible should be marked. The incision should curve at least two finger lengths away from the mandible to avoid injury to the mandibular branch of the facial nerve. The actual incision needed is dependent on the bifurcation location and should be correlated to standard localizing landmarks such as the trachea, cricoid, etc. The incision is made at the medial border of the sternocleidomastoid muscle.

Exposure

The incision is sharply incised through the dermis only. Bovie (initially on cut) is used to open the subdermal layer and then the subcutaneous fat and platysma (on coag).

There is an avascular plane medial to the SCM (don’t get into the SCM) that can be identified and dissected through with Metzenbaum scissors.

Debakey forceps are used deep to the platysma. Wide spreading motions should be used with cutting only when a band is see-through. Vessels should be preserved when possible but small ones may be cauterized if needed. Larger veins are tied with 2-0 silk sutures and then transected. The carotid is frequently palpated to confirm trajectory, but care must be taken not to aggressively manipulate it to avoid plaque emboli. A wide dissection plane should be made down to the carotid sheath. The sheath is also spread open with scissors inferiorly and superiorly, which should be parallel to the vessel.

Key landmarks to avoid the hypoglossal nerve are the posterior belly of the digastric muscle and the facial vein, both of which tend to be superficial and inferior to it. A Weitlaner retractor may be used at first but once the vessels are dissected Dr. Friedlander uses a retractor called a Henley to help pull the superior edge out of the way.  The blade of the Henley should be superficial to the hypoglossal nerve.

Once the vessel is exposed, the scissors are used to dissect deep to the vessel and a right-angle snap is used to confirm circumferential dissection. A blue vessel loop is threaded around the superior thyroid artery twice and retracted with a curved hemostat, which is attached to the drape.

At this point Dr. Friedlander asks the anesthesiologist to administer 5000 units of heparin.

The ICA, ECA, and CCA are threaded with umbilical tape once the right angle is well visualized under the vessel and a clear piece of plastic tubing is slid down the umbilical tape using the Rummel tourniquet.

The tape is then secured with a curved hemostat which are allowed to free float on the table. They are not snapped to the drape. Prior to cross clamping, the SBP is raised to 160 depending on patient context. A Sundt shunt should be in the room at this point. The vessels are clamped in the following order: “ICE”. The internal and external are clamped with aneurysm clips and the umbilical tape draped over them to retract them out of the way. The CCA is clamped with a DeBakey vascular clamp.

A “bull dog” clamp is available if needed, especially if the ICA is particularly calcified. The umbilical tape and plastic tubing can be synched down against a vessel in an urgent setting.

Arteriotomy

Three minutes are allowed to pass to observe for EEG changes. In the absence of such, you proceed. Otherwise, a Sundt shunt may be needed on the field. An incision is made quickly with an 11 blade on the common carotid after the planned incision is marked out. Dr. Friedlander prefers to stay out of the plaque if possible. Once a cut is made, a 4 Penfield is advanced to dissect a plane and Potts scissors are used to extend the incision. The plane is circumferentially dissected with the 4 Penfield at the level of the CCA, a right-angle clamp is placed under the plaque and sharply cut with the 11 blade. Using DeBakeys the plaque is gently pulled out of the ECA and ICA as superiorly as possible. Heparin irrigation is used to flush and then a cupped forceps and suction are used to identify and remove lose fragments throughout the inner lumen of the vessels.

A 5-0 prolene suture (with a BV-1 needle) with both needles is used to secure the superior edge of the arteriotomy. Both needles are inserted from inside the vessel outward and should be close to each other at the entry and exit to avoid stenosis. Seven knots are thrown, and the longer piece of the suture is cut. Your hands should be wet when tying. The suture is then run to the midpoint of incision using very small bites to avoid stenosis. A shodded snap is used to hold the needle at this point. Another 5-0 prolene is used to sew another continuous running suture line from inferiorly to midpoint. This one can be started with a standard bite rather than the technique used superiorly. Once the suture line is complete, both threads are taken in hand.

The vessels are back bled at this time starting with ECA and then the CCA, which are both clamped. Then, the ICA is opened and then clamped.

The sutures are tied and the SBP reduced to below 160 (unless the patient has severe >95% stenosis when the SBP is reduced to below 130). The ligature around the superior thyroid is released. The vessels are opened in the following order: External, Common clamp is released and held in place for 10 beats and then clamped, then the internal is released and after 10 beats the common in again released. Any significant (pumping) bleeding from the suture line is addressed with interrupted throws. Surgicel is placed on the incision line. Once hemostasis is achieved, half a contained of Avitene is placed in the surgical bed.

Closure

A running 3-0 Vicryl closure of the platysma, interrupted inverted on the subdermal layer and running subcuticular 4-0 Biosyn closure of the skin. Steri-strips transversely over the incision.

Orders

Please use the CEA order set. The patient should be put on full dose aspirin. Ask for neck circumference measurements to be done with neuro checks. Use 24 hours post-op antibiotics. SBP cap 160 for most cases with patients going to PACU for several hours and then stepdown. SBP cap under 130 for patients with >95% stenosis and possibly will go to ICU.