DATE OF PROCEDURE: MM/DD/YYYY
PROCEDURE PERFORMED: Left carotid bifurcation endarterectomy with saphenous vein patch angioplasty and completion arteriogram.
OPERATION IN DETAIL: The patient was placed on the operating room table in a supine position. General anesthetic was induced and maintained with an oral endotracheal tube. EEG monitoring was utilized. A radial arterial line was placed. The head was turned to the right, gently, and a roll was placed beneath the left scapula. The head was cradled on a foam headrest taking care not to hyperextend the neck. EEG was of low amplitude bilaterally and stable in this position. The left thigh was also laterally rotated and flexed at the hip and knee. The patient was padded with blankets to make the area of the saphenous vein prominent. The left thigh was shaved and then the course of the saphenous vein was marked with a marking pen. The left side of the neck and chest as well as the left thigh were then prepped with DuraPrep and draped with sterile towels and drapes, including Ioban and Steri-Drapes, over each operative site.
PROCEDURE PERFORMED: Left carotid bifurcation endarterectomy with saphenous vein patch angioplasty and completion arteriogram.
OPERATION IN DETAIL: The patient was placed on the operating room table in a supine position. General anesthetic was induced and maintained with an oral endotracheal tube. EEG monitoring was utilized. A radial arterial line was placed. The head was turned to the right, gently, and a roll was placed beneath the left scapula. The head was cradled on a foam headrest taking care not to hyperextend the neck. EEG was of low amplitude bilaterally and stable in this position. The left thigh was also laterally rotated and flexed at the hip and knee. The patient was padded with blankets to make the area of the saphenous vein prominent. The left thigh was shaved and then the course of the saphenous vein was marked with a marking pen. The left side of the neck and chest as well as the left thigh were then prepped with DuraPrep and draped with sterile towels and drapes, including Ioban and Steri-Drapes, over each operative site.
The saphenous vein was harvested from the thigh simultaneously with exposure of the carotid artery in the neck. In the thigh, the branches of the saphenous vein were divided between #4-0 silk ligatures. The vein was ligated both proximally and distally and then placed in heparinized saline. A longitudinal incision was then made along the anterior border of the sternocleidomastoid muscle. The incision was deepened down through the subcutaneous tissue and platysma with electrocautery. The external jugular veins were divided between #4-0 silk ligatures.
The incision was deepened along the anterior border of the sternocleidomastoid muscle to expose the internal jugular vein. Branches coming from the anterior surface of the jugular vein were divided between #4-0 silk ligatures. The common carotid artery was identified and dissected circumferentially after lowering the incision. Vagus nerves were identified and protected throughout its course in the neck. The hypoglossal nerve was identified superiorly and protected throughout its course in the neck. The bifurcation was low. Internal carotid artery was dissected above the region of the bulb. The external carotid artery was dissected circumferentially above the superior thyroid artery. The superior thyroid artery was ligated with a #2-0 silk ligature. He was then given 10,000 units of heparin. After this had circulated for about 5 minutes, atraumatic vascular clamps were placed upon the internal carotid, the common, and the external carotid artery.
The incision was deepened along the anterior border of the sternocleidomastoid muscle to expose the internal jugular vein. Branches coming from the anterior surface of the jugular vein were divided between #4-0 silk ligatures. The common carotid artery was identified and dissected circumferentially after lowering the incision. Vagus nerves were identified and protected throughout its course in the neck. The hypoglossal nerve was identified superiorly and protected throughout its course in the neck. The bifurcation was low. Internal carotid artery was dissected above the region of the bulb. The external carotid artery was dissected circumferentially above the superior thyroid artery. The superior thyroid artery was ligated with a #2-0 silk ligature. He was then given 10,000 units of heparin. After this had circulated for about 5 minutes, atraumatic vascular clamps were placed upon the internal carotid, the common, and the external carotid artery.
An arteriotomy was made in the common carotid artery. It was then extended proximally and then distally through the internal carotid bulb region and some more distal to the internal carotid artery. There was marked hemorrhagic plaque within the bulb. A previously heparinized 3 x 4 mm shunt was prepared. It was necessary to gently dilate the internal carotid artery with a 2, 2.5, and 3 mm dilator before placing the shunt. The shunt was then placed within the internal carotid artery securing with large Javid shunt clamp. Backbleeding was almost negligible. A right drain was quickly placed within the common carotid artery and secured with a large Javid shunt clamp which was then exchanged with a doubly looped maxi loop. Continuous wave Doppler confirmed flow within the shunt.
Endarterectomy was then done in the usual fashion. After lowering of the arteriotomy, the intima was divided under direct vision using the Potts scissors. The endarterectomy then proceeded distally into internal carotid artery where a nice tethering endpoint was achieved. The external carotid was endarterectomized using an aversion-type of technique and loose adherent strands of media were removed from the endarterectomized surface with fine mosquito hemostats. The surface of the artery was repeatedly irrigated with heparinized saline and low-molecular weight dextran.
Endarterectomy was then done in the usual fashion. After lowering of the arteriotomy, the intima was divided under direct vision using the Potts scissors. The endarterectomy then proceeded distally into internal carotid artery where a nice tethering endpoint was achieved. The external carotid was endarterectomized using an aversion-type of technique and loose adherent strands of media were removed from the endarterectomized surface with fine mosquito hemostats. The surface of the artery was repeatedly irrigated with heparinized saline and low-molecular weight dextran.
After completing the endarterectomy, the saphenous vein patch was prepared by incising it longitudinally. A segment without valves was selected. The vein was then trimmed longitudinally so it was about 0.25 inch wide. The vein patch was then sutured in place with running #6-0 Prolene. After completing the posterior suture line, a 20 gauge Angiocath was placed retrograde through the superior carotid artery, near the common carotid artery, and secured with a #4-0 silk ligature. This was used later for completion arteriogram.
The anterior suture line was then closed until the shunt prevented placement of the last two sutures. The shunt was then removed. The artery was found with forward and backbleeding, and it was again flushed with heparinized saline. The arteriotomy closure was then closed. Flow was restored at the external carotid artery, and after about 15 seconds, the internal carotid artery was opened. There were easily palpable pulses in the internal, external, and common carotid artery with no evidence of dissection. Continuous wave Doppler signals were satisfactory in all three arteries.
The anterior suture line was then closed until the shunt prevented placement of the last two sutures. The shunt was then removed. The artery was found with forward and backbleeding, and it was again flushed with heparinized saline. The arteriotomy closure was then closed. Flow was restored at the external carotid artery, and after about 15 seconds, the internal carotid artery was opened. There were easily palpable pulses in the internal, external, and common carotid artery with no evidence of dissection. Continuous wave Doppler signals were satisfactory in all three arteries.
The completion arteriogram was then done. This revealed a widely patent internal and external carotid artery. This was done by injecting approximately 4 mL of Optiray through the catheter in the superior thyroid artery. The catheter was then removed, and the superior thyroid artery was ligated with a #4-0 silk ligature. Heparin was then reversed with 50 mg of protamine sulfate.
After hemostasis was achieved, the thigh wound was closed with running #3-0 Vicryl for the subcutaneous tissue and running #4-0 Vicryl subcuticular suture for the skin. The neck wound was then closed with running #3-0 Vicryl for the platysma and running #5-0 Vicryl subcuticular suture for the skin. Sterile bandages were applied, and he tolerated the procedure without complications. All sponge, needle, and instrument counts were correct. The patient left the operating room to go to the recovery room in satisfactory condition without obvious neurologic deficits.
After hemostasis was achieved, the thigh wound was closed with running #3-0 Vicryl for the subcutaneous tissue and running #4-0 Vicryl subcuticular suture for the skin. The neck wound was then closed with running #3-0 Vicryl for the platysma and running #5-0 Vicryl subcuticular suture for the skin. Sterile bandages were applied, and he tolerated the procedure without complications. All sponge, needle, and instrument counts were correct. The patient left the operating room to go to the recovery room in satisfactory condition without obvious neurologic deficits.
