You are due to operate on a 70 year old lady who had an episode of TIA 10 days ago. She has two Doppler scans the last of which is 7 days old showing a very tight left ICA stenosis > 90 %. She has a short neck and limited neck extension.
Discuss your preoperative and operative approach principles.
In the same case you identify that she has a low bifurcations and a tortuous elongated ICA.
What are the common pitfalls and how to avoid them?
3 Comments
Ahmed Nasr Mohammed Abdelfattah Ahmed Osman
preop: optimise bp, diabetes, cardiac status, start aspirin and statin, plan airway with anesthesia because of short neck and limited extension
op: good positioning with shoulder roll, careful dissection, protect cranial nerves, use shunt if needed, patch closure
pitfalls with low bifurcation and tortuous ica: difficult exposure, cranial nerve injury, kinking after repair, incomplete endarterectomy
avoid by extending incision if needed, mobilising artery carefully, correcting kinking, checking flow and lie before closure
A1:
Pre op labs ECG Echo baseline neurological assessment CTA for anatomical considerations as level of bifurcation vessel tortiousity lesion location and contra lateral side
Councelling and consenting the patient
ENT cosultation in case of need to mandible sublaxation
Operative
CEA is the procedure of choice with longitudinal neck incision along ant border of sternomastoid m explore the CCA and bifurcation control of vv selection of shunting and type of anesthesia according to the surgeon preference
CAS in certain cases with hostile neck
A2:
In case of tortious ICA eversion CEA with shortening of the ICA and reimplantation in the bifurcation end to end
Care must be taken to avoid hypoglossal nerve injury in low bifurcation scenario
A case of symptomatic critical Left severe ICA stenosis for intervention within 2 weeks of TIA.CEA still standard, but requires careful planning, longer incision, and experienced surgeon. However, CAS could be considered if patient has high anesthetic risk or high surgical risk as hostile neck,previous surgery/radiotherapy, severe co-morbidities )Preoperative:*Airway: preoperativeanesthesia assessment, plan for fiber-optic laryngoscope if GA, regional anesthesia may be preferred.
*Neurological monitoring with baseline neuro status, EEG
*Cardiac risk assessment: rule out unstable coronary disease
*Control blood pressure, glucose, statins.
Operative :*Positioning : Supine with head turned away from operative side. Place a shoulder roll to maximize neck extension. In short neck → optimize exposure by carefully positioning; avoid over-extension to prevent cervical spine injury
*Skin Incision & Exposure : Long oblique incision along the anterior border of the sternocleidomastoid (SCM). Divide platysma; mobilize SCM laterally. Open carotid sheath to expose common carotid artery (CCA), bifurcation, ICA and ECA.
*Vessel Control : Dissect and encircle CCA, ICA, and ECA with vessel loops.
Identify and protect cranial nerves: hypoglossal (XII), vagus (X), marginal mandibular branch, ansa cervicalis.
Administer heparin before clamping.
Apply clamps in sequence: ICA → ECA → CCA.
*Endarterectomy Technique : Longitudinal arteriotomy from CCA into ICA.
Perform standard endarterectomy.
Closure: Patch angioplasty (prosthetic or vein) to reduce restenosis risk.
Shunt: used selectively (if stump pressure low, poor backbleeding, or if GA with neuro monitoring abnormal).
*Completion & Closure : Flush vessels before clamp release (ECA first, then ICA, then CCA). Ensure meticulous hemostasis. Insert suction drain to prevent postoperative neck hematoma. Layered closure without tension.
Common pitfalls and how to avoid them*Short Neck & Limited Extension:
Pitfall: Poor exposure → risk of vessel/nerve injury, longer clamp time.
Avoidance: Extend incision adequately, mobilize SCM/omohyoid if needed, use head positioning aids. Consider loupes or headlight.
*Low Bifurcation:
Pitfall: Difficult distal control of CCA; higher risk of injury to thoracic duct (left side) and recurrent laryngeal nerve.
Avoidance: Extend incision inferiorly, dissect carefully along CCA, identify nerves early.
*Tortuous / Elongated ICA:
Pitfall: Vessel redundancy → kinking after closure, technical difficulty placing shunt.
Avoidance: Gentle mobilization, assess lie of ICA after closure. If kink persists → perform resection with end-to-end anastomosis or reimplantation onto CCA.
*Cranial Nerve Injury: Hypoglossal, marginal mandibular, vagus, spinal accessory at risk.
Avoidance: Careful dissection, use of vessel loops instead of clamps close to nerves.
*Hemodynamic Instability:
Pitfall: Post-op hypertension/hypotension → hyperperfusion or stroke.
Avoidance: Continuous BP monitoring, treat promptly with titratable IV antihypertensives.
*Hematoma & Airway Compromise:
Pitfall: Inadequate hemostasis, lack of drain.
Avoidance: Meticulous closure, secure hemostasis, routine suction drain, close in layers without tension.
preop: optimise bp, diabetes, cardiac status, start aspirin and statin, plan airway with anesthesia because of short neck and limited extension
op: good positioning with shoulder roll, careful dissection, protect cranial nerves, use shunt if needed, patch closure
pitfalls with low bifurcation and tortuous ica: difficult exposure, cranial nerve injury, kinking after repair, incomplete endarterectomy
avoid by extending incision if needed, mobilising artery carefully, correcting kinking, checking flow and lie before closure
A1:
Pre op labs ECG Echo baseline neurological assessment CTA for anatomical considerations as level of bifurcation vessel tortiousity lesion location and contra lateral side
Councelling and consenting the patient
ENT cosultation in case of need to mandible sublaxation
Operative
CEA is the procedure of choice with longitudinal neck incision along ant border of sternomastoid m explore the CCA and bifurcation control of vv selection of shunting and type of anesthesia according to the surgeon preference
CAS in certain cases with hostile neck
A2:
In case of tortious ICA eversion CEA with shortening of the ICA and reimplantation in the bifurcation end to end
Care must be taken to avoid hypoglossal nerve injury in low bifurcation scenario
A3:
Complications
Early
Stroke hematoma HPS CNI RLN injury hypo hypertension
Late
Infection restenosis
A case of symptomatic critical Left severe ICA stenosis for intervention within 2 weeks of TIA.CEA still standard, but requires careful planning, longer incision, and experienced surgeon. However, CAS could be considered if patient has high anesthetic risk or high surgical risk as hostile neck,previous surgery/radiotherapy, severe co-morbidities )Preoperative:*Airway: preoperative anesthesia assessment, plan for fiber-optic laryngoscope if GA, regional anesthesia may be preferred.
*Neurological monitoring with baseline neuro status, EEG
*Cardiac risk assessment: rule out unstable coronary disease
*Control blood pressure, glucose, statins.
Operative :*Positioning : Supine with head turned away from operative side. Place a shoulder roll to maximize neck extension. In short neck → optimize exposure by carefully positioning; avoid over-extension to prevent cervical spine injury
*Skin Incision & Exposure : Long oblique incision along the anterior border of the sternocleidomastoid (SCM). Divide platysma; mobilize SCM laterally. Open carotid sheath to expose common carotid artery (CCA), bifurcation, ICA and ECA.
*Vessel Control : Dissect and encircle CCA, ICA, and ECA with vessel loops.
Identify and protect cranial nerves: hypoglossal (XII), vagus (X), marginal mandibular branch, ansa cervicalis.
Administer heparin before clamping.
Apply clamps in sequence: ICA → ECA → CCA.
*Endarterectomy Technique : Longitudinal arteriotomy from CCA into ICA.
Perform standard endarterectomy.
Closure: Patch angioplasty (prosthetic or vein) to reduce restenosis risk.
Shunt: used selectively (if stump pressure low, poor backbleeding, or if GA with neuro monitoring abnormal).
*Completion & Closure : Flush vessels before clamp release (ECA first, then ICA, then CCA). Ensure meticulous hemostasis. Insert suction drain to prevent postoperative neck hematoma. Layered closure without tension.
Common pitfalls and how to avoid them*Short Neck & Limited Extension:
Pitfall: Poor exposure → risk of vessel/nerve injury, longer clamp time.
Avoidance: Extend incision adequately, mobilize SCM/omohyoid if needed, use head positioning aids. Consider loupes or headlight.
*Low Bifurcation:
Pitfall: Difficult distal control of CCA; higher risk of injury to thoracic duct (left side) and recurrent laryngeal nerve.
Avoidance: Extend incision inferiorly, dissect carefully along CCA, identify nerves early.
*Tortuous / Elongated ICA:
Pitfall: Vessel redundancy → kinking after closure, technical difficulty placing shunt.
Avoidance: Gentle mobilization, assess lie of ICA after closure. If kink persists → perform resection with end-to-end anastomosis or reimplantation onto CCA.
*Cranial Nerve Injury: Hypoglossal, marginal mandibular, vagus, spinal accessory at risk.
Avoidance: Careful dissection, use of vessel loops instead of clamps close to nerves.
*Hemodynamic Instability:
Pitfall: Post-op hypertension/hypotension → hyperperfusion or stroke.
Avoidance: Continuous BP monitoring, treat promptly with titratable IV antihypertensives.
*Hematoma & Airway Compromise:
Pitfall: Inadequate hemostasis, lack of drain.
Avoidance: Meticulous closure, secure hemostasis, routine suction drain, close in layers without tension.