Common carotid artery
Fig. 38.5. Following completion of the arteriotomy, the plaque is identified using a #4 Penfield dissector or a Freier elevator. The plaque is divided sharply in the common carotid artery and dissected from the internal carotid artery. Most of the time, the plaque will thin and "feather" out, allowing it to be separated from the distal arterial wall with gentle traction. Occasionally, it will need to be sharply divided distally.
plaque is then removed from the arterial wall using a Freier elevator or a Penfield dissector. Plaque is removed from the lateral wall of the arteriotomy, then dissected medially on the CCA and then transected proximally. Attention is then turned to the ICA, where plaque is also dissected from lateral to medial and a concerted attempt is made to leave a smooth surface. Finally, attention is then focused on the orifice of the ECA and, with the use of vascular forceps, the entire plaque can be dissected off the vessel with gentle eversion in order to reach as distally as possible (Fig. 38.6). Inadequate ECA plaque removal can lead to thrombosis and complete occlusion of the carotid tree. The luminal surface is carefully inspected after plaque removal, while the site is being irrigated with heparinized saline. Visible debris should be meticulously removed so as to create a lumen that is as smooth as possible. Running 5-0 or 60 Prolene from distal to proximal end of the vessel is then used to close the site (Fig. 38.6). If a patch, such as a Hemashield, or a vein patch is used, it is placed over the arteriotomy site and cut to the exact length of the opening. The ends of the patch are anchored to the arteriotomy site and a running 6-0 Prolene suture used to close the patch. The internal carotid artery is briefly released just before the final sutures so as to assess the patency of the vessel and flush residual debris. The clamps are then removed in the following sequence: ECA, CCA and ICA. Once the clamps are removed, the suture lines are inspected for leaks. Surgicel, and sometimes a 6-0 Prolene, suture are needed to control a persistent arterial leak. The carotid sheath is then
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