Editing Carotid endarterectomy (section)

== Operative technique (CEA) ==

* Anaesthetic
** GA/regional/LA
* Positioning
** Neck extension
** Padded ring under head
** Tube on opposite corner of mouth
** Access to high lesions can be improved by naso-tracheal intubation - keeping mouth closed allows an extra few cm of access between mandible and mastoid, and allows potential TMJ subluxation
* Incision
** Longitudinal incision parallel to medial border of SCM
* Exposure
** Divide platysma, mobilise medial SCM
** Find external jugular and greater auricular nerve and retract laterally
** Enter carotid sheath
** Medial border of IJV dissected and retracted laterally - look out for facial vein at level of carotid bifurcation and ligate/divide it if necessary
** Vagus nerve identified - posterior between IJV and CCA
** CCA controlled circumferentially with an umbilical tape
** Identify ansa cervicalis (medial to distal CCA) and follow it cranially to hypoglossal nerve
** Superior thyroid artery (medial border of carotid bifurcation) and controlled
** ECA and ICA encircled with vessel loops
** Be aware of carotid body
* Procedure
** 70-100 units/kg of heparin IV, then wait 3 mins
** ICA clamped - distal to plaque
** CCA and ECA clamped
** Conventional procedure
*** Vertical arteriotomy and closure with patch angioplasty
*** Begun in CCA and continued through bifurcation into ICA
*** Patch can be Dacron, PTFE or bovine pericardium