Lines

A pre-induction arterial line is placed. Keep the systolic blood pressure at the patient's baseline, more or less the same as the pre-induction SBP. 
Place a Foley. 

Monitoring

8-channel EEG, SSEPs

Positioning

Use a rolled blanket for a bump. Lengthwise between the shoulders. Don't roll it tightly, allow the cross section of the blanket to assume more of an ellipsoid shape. 

Tape the endotracheal tube to the side opposite the pathology. 

Turn bed 180. Both arms tucked at the sides. 
Two Layla bars, one on each side. The one on the side opposite the pathology should be on the head of the bed. Push the brackets down a few inches from the top of the bed (the bracket in the image below was too high)

Tape the jaw back and secure to the bed.

The Layla bars are attached like so. The red arrow marks the direction of the patient's face. This was for a left sided pathology. 

The bar on the side ipsilateral to the pathology is pointed straight up then inclined a little towards the patient such that it's touching their ipsilateral shoulder. 

The bar on the contralateral side is up further north in the bed, below the plane of the face, and also oriented straight up and inclined a little towards the patient. 

Marking

Mark the angle of the mandible (purple) and medial edge of the sternocleidomastoid (red dotted line). The incision is about 5 cm long, along the medial edge of the sternocleidomastoid. If the bifurcation is high enough that the incision would extend past the edge of the mandible, curve the incision back towards the back of the neck. The incision begins to curve when it comes within one finger-breadth of the angle of the mandible (lime green line).  

Approach

Make the skin incision with the 15-blade then Bovie to the platysma. Open the platysma in line with the incision. 

Dissect through the fat and subcutaneous tissue to the carotid bifurcation. 

Dissect out the ICA, ECA, and CCA. 

Place a vessel loop around each vessel. Pass it underneath the vessel once then secure the two ends of the loop together with two wet clips, one proximal and one distal. Then use a hemostat to secure the vessel loop to the drape. 

Pass a length of umbilical tape underneath the vessel, also just once. Pass a short length of plastic tubing over the paired ends of the umbilical tape using the Rommel. The umbilical tape should be outside the vessel loops, i.e. on the side further away from the carotid bifurcation. Secure the ends of the umbilical tape with a hemostat. 

Cut a circle out of a white OR towel and place over the field. Pass only the umbilical tape through the opening in the white towel. 

Endarterectomy

Give 5000 units of IV heparin. 

Ask anesthesia to maintain the systolic blood pressure between 140 and 160. 

Clamp the vessels. ICA then CCA then ECA. Clamping the vessels outside the umbilical tape (i.e. on the side further from the carotid bifurcation). 

Use curved temporary aneurysm clips for the ICA and ECA. 

Clamp the CCA with a DeBakey vascular clamp. 

Mark a line along the ICA and CCA. 

Use the 11 blade to start the arteriotomy on the CCA, then carry this through with the Potts scissor. 

Use the endarterectomy dissector (looks like a Rhoton 6 but is included in the endarterectomy set) to dissect the plaque from the vessel. 

Continuously irrigate with heparinized saline on the olive-tip syringe. 

Closure

Use a 6-0 Prolene suture with double ended needle to close the arteriotomy. You will need two sutures (a total of 4 needles). 

Start at the top corner of the arteriotomy, on the ICA. Pass the first needle from inside to outside, at the corner. Pass the second needle from inside to outside at the corner as well. 

Tie the two ends of the suture together. Place a shodded hemostat on the shorter end and snap to the drape. Begin sewing the ICA and stop at the midpoint of the arteriotomy. Do the same maneuver with the other double-ended needle at the corner of the arteriotomy on the CCA. Sew up towards the other suture. When the two suture lines meet, tie the two together. 

Release the occlusion on the ECA first then CCA then ICA. 

Irrigate until dry then put a piece of Surgicel against the suture line. 

Place a JP drain. 

Close the platysma and dermal layers with 3-0 Polysorb. Run a 4-0 Biosyn subcuticular on the skin. Put a little skin glue. 

Cover both the incision and the drain exit site with a Primapore. 

Orders

Carotid endarterectomy order set. 

SBP floor 100, ask attending re: cap. Sometimes it is 150. 

ICU admission. 

No imaging

ASA81