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Right Carotid Endarterectomy and Bovine Pericardial Patch Angioplasty

DETAILS OF OPERATION:  The patient was taken to the operation room.  In supine position, under adequate general anesthetic, the neck was prepped with povidone solution, draped using lap sheets and towels.  A transverse incision was made and the bleeding was controlled using Bovie.  The sternocleidomastoid was reflected posteriorly as was the internal jugular vein after clamping and ligating several anterior branches with 2-0 and 3-0 silk.  The common carotid was identified and the patient was given 10,000 units of heparin.  Dissection was carried superiorly, identifying and preserving the hypoglossal and vagus nerves.  The internal and external branches were delineated and vessel loops were placed around each.  A Rumel tourniquet was placed around the common carotid and the shunt was prepared in case it needed to be used.  The common carotid was cross-clamped and brain monitoring reported that there was no alteration in signal.  An incision was made extending from the common carotid up to the internal carotid.  Careful endarterectomy was then performed using a Penfield elevator.  It was noted the patient had heavily calcific plaque with superficial ulceration.  The plaque was finally removed, and after ensuring that there was no loose debris, attention was turned to closure.  A piece of bovine pericardium was brought onto the field and then fashioned as a patch.  This was sutured in place using 6-0 Prolene in continuous fashion.  Upon completing the suture line, backbleeding was allowed.  The suture line was tied down and flow was established, first of the external and then the internal.  The heparin was partially reversed with protamine, and after noting adequate hemostasis, attention was turned to closure.  Closure was performed using 3-0 Vicryl in continuous fashion to the subcutaneous tissue and 4-0 Vicryl in continuous subcuticular fashion for the skin.  After placing an adequate dressing and noting a normal neurologic examination, the patient was taken to the recovery area in good condition.