In this procedural case review, vascular surgeon Dr. Samuel Steerman performs a right carotid endarterectomy on a woman in her 60s who experienced a stroke related to carotid artery plaque. The video highlights key surgical steps, discusses the role of carotid revascularization in secondary stroke prevention, and emphasizes the importance of tailoring intervention strategies to each patient's anatomy, symptoms, and overall risk profile.
Hi, I'm Samuel Steerman. I'm a vascular surgeon with Centerovascular Specialists, and we have a unique opportunity to bring you to the operating room today, because we have a patient in her 60s who suffered a stroke from carotid plaque. Our plan today is to do a carotid endarterectomy, and while we offer transcervical carotid stenting and transfemoral carotid stenting. We tailor each individual case to the individual patient for a variety of factors and have recommended carotid end arterectomy. Our plan is to make an incision on the side of the neck, expose the carotid artery, remove the plaque, and then sew everything all up. We'll bring it to the operating room at Virginia Beach General to continue. Welcome to Virginia Beach General. This is operating room 4, and we have our patient under general anesthesia. We've just anesthetized the neck, uh, and the patient is laying on their back with their head at the top of the screen and their body down lower. This is the right side of the neck, and oblique incision is made in the right side. This is carried down through the subcutaneous tissue. Uh, below this, you'll see the platysma, which we cut through as well. Typically a small incision is all that's necessary to expose the carotid for endarterectomy. We're starting to dissect the carotid free from the surrounding structures. There's several muscles and veins that are overlying this that need to be divided. It's important to avoid the nerves in this area, which is why there's not a lot of cutting done, but more spreading and careful dissecting. You can see at the bottom of the screen, the common carotid artery is starting to be dissected free from the surrounding structures, and then right where that instrument was is the bifurcation or the split. This is the external carotid artery that we're putting the right angle around, and then this is a vessel loop, the red silastic device that's being encircled right now. It helps us control those blood vessels and identify them for clamping. The external carotid branch goes to the face and is the less important carotid, and this right now is the internal carotid that's being encircled. This is the one that goes straight up to the brain, and the reason that we're doing this end arterectomy to avoid embolization of that plaque. Right now, the common carotid artery below the bifurcation is being encircled with an umbilical tape, um, and that's to prepare for clamping. Some of the tenets of vascular surgery involve clamping the blood vessels before operating on them, so we're we're preparing for that right now and dissecting it free. There's the clamp first placed on the internal carotid artery to the top left of your screen in the common carotid, and the carotid artery is incised. The blood that's in that small section is evacuated, and you can begin to see that plaque that we've identified that needs to be removed. This is the incision is carried up to the internal carotid artery to the point beyond the plaque and also down into the common carotid artery. This is a temporary shunt that sometimes is placed, and it's bringing blood flow around that area where the artery is opened, as we operate on it to preserve blood flow to the brain. Now this is the best part, this is the endarterectomy, we create the plane between the outside of the artery, the middle of the outside of the artery, and that plaque, and you can see it coming out as it's teased away from the blood vessel really nicely. The endarterectomy is done, and if you look at the specimen, you can see. The undulations, the irregular surface, the ruptured plaque, the adherent thrombi that probably contributed to this patient's stroke. Now I want this bed to be as perfect as possible and remove the debris to the best of my ability, and that's what we're working on right now, tediously dissecting away all of those little pieces so that they don't break off and embolize to the brain to cause another stroke, one of the risks of the procedure. If we were to close up this artery primarily, meaning just suture end to end, there's a concern that it could be narrowed, so this is a small strip of bovine pericardium, a portion of the cow pericardium. That's used to bridge that gap, so it's sutured to each side to make sure that artery is wide open and there's able to be lots of blood flow going through that artery. We're now tailoring the proximal portion on the common carotid artery and placing a stitch to just not bunch up too much tissue and give it a nice closure. You notice the shunt is still in place and still providing circulation up to the brain, and that's going to be put in place until just before the last stitch is placed, and we'll remove it along the way. This is somewhat fine suture, a 60 suture, about the size of a human hair, and you can see the shunt with the tie on it is being removed prior towards finishing the patch closure. Just as the proximal portion comes out, the common carotid is clamped, and as the distal portion comes out, the distal portion is clamped. Here's the last couple of bites that are done somewhat expeditiously as. The endarterectomy bed is closed. After we do this, we'll remove the clamps in a very specific fashion and in a manner to avoid embolization of anything that may be in that carotid bed. You can see I'm putting pressure on the internal carotid artery as we remove the common carotid clamp, so any debris that may or may not be in there goes to the. Internal carotid artery until we restore blood flow to the internal. This is the finished product, and to be sure that this bed is as good as we can possibly make it, we do a completion duplex, an ultrasound right on the table before the skin is closed to make sure that the endarterectomy bed is perfectly clean and lots of blood flow through the area. Then a meticulous monochrole dissolvable suture closure, and the patient would go home the following day.
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