Editing Vascular techniques (section)

== Endarterectomy ==

* Principles:
** Removal of atherosclerotic plaques that compromise the arterial lumen
** Usually results in removal of the thickened intima and inner media
** Should not be performed in an aneurysmal artery - adventitia too weak
** Need a smooth transition at the endpoint of the endarterectomy plane in the direction of arterial flow
* Techniques
** Open endarterectomy
*** Open the artery longitudinally at the site of disease
*** Plaque separated from the wall in the direction of the arteriotomy
**** Hold the edge of the adventitia with the forceps and pull it away from the plaque
**** Then develop the plane between the plaque and the media or adventitia
**** Develop the plane on both sides and move posteriorly until it becomes circumferential
*** When a normal part of the wall is reached, the plaque either 'feathers out' or is transected flush with the arterial wall without leaving a significant protruding edge (if that is done, need to tack it down with sutures to avoid plaque lifting/dissection/thrombosis)
**** Tack down by putting one end of the suture in the remaining plaque, 1mm distal to the endpoint, and the other end at the junction of the endarterectomy and the endarterectomised surface
**** Some believe that tacking the proximal endpoint is unnecessary because the flow doesn't lift it
** Semiclosed
*** Artery opened in a proximal and distal location
*** Plaque cored out between the two holes
*** Avoids big longitudinal arteriotomy
** Eversion
*** Transect the artery and evert the adventitia
*** Plaque should come straight off
*** Need to expose a long segment of artery
** Orificial
** Extraction