Carotid endarterectomy (CEA)

Anatomy Review

• but often this is rotated such that ICA is abutting tracheo-esophageal space → “kissing carotids”

• superior thyroid artery

• ascending pharyngeal
• very relevant surgically

• deep to SCM, in front of longus colli

• branches either coming off posteriorly or anteriorly

Booking

• awake vs. asleep

• neurophys vs. TCDs

Trivia

• what is the largest muscle in a horse? Platysma

Incision

Exposure:

• SCM takes you to carotid sheath. work along anterior border, mobilize laterally to come on the carotid sheath

• Common facial vein: generally found at carotid bifurcation
• not always present, can also be duplicated, truplicated into smaller branches
• generally speaking, will ligate it to mobilize the jugular vein

• Facial artery: found about 1-2 cm anterior to angle of mandible (you can palpate on your own head)
• marginal mandibular nerve runs right under this
• fixed retraction → marginal mandibular palsy (lower lip muscle weakness) → patients cannot drink!

• Vagus nerve:
• the third structure in carotid sheath
• generally deep to IJV (lateral) and deep to ICA (medial) however can also be superficial

• Hypoglossal nerve:
• muscular landmark: posterior belly of digastric muscle

Occluding carotid

• heavily calcified plaques thin out wall, do not punch through as you’re creating plane!

Optional: shunting

• generally do not need this if clamp time < 20 minutes or so

Closure