Distal internal carotid exposure: A simplified technique for temporary mandibular subluxation

Abstract

Distal internal carotid artery exposure can be technically demanding even for experienced vascular surgeons. Although a variety of techniques have been described to facilitate such exposure, temporary mandibular subluxation has emerged as the simplest and least debilitating approach. Current techniques for maintaining temporary mandibular subluxation during distal internal carotid artery procedures, including maxillomandibular arch bar fixation and circummandibular/transnasal wiring, have been time consuming and associated with complications. Over the last 4 years a new simplified technique of temporary mandibular subluxation fixation has been used in 14 patients requiring distal internal carotid exposure. Indications for operation included extended carotid endarterectomy (8), carotid body tumor excision (2), repair of distal internal carotid artery trauma (2), and repair of postendarterectomy pseudoaneurysm (2). Among patients with healthy teeth, unilateral temporary mandibular subluxation was maintained by interdental wiring from the ipsilateral mandibular bicuspids to the contralateral maxillary bicuspids. In edentulous patients or those with chronic periodontal disease, temporary mandibular subluxation was maintained with diagonal wiring between maxillary and mandibular Steinmann pins. No instances of malocclusion, dental injury, or local infection were observed. Transient postoperative cranial nerve dysfunction was observed in three patients. Transient ipsilateral temporomandibular joint pain occurred in three patients. Two patients developed permanent cranial nerve injuries unrelated to temporary mandibular subluxation. These data suggest that temporary mandibular subluxation by diagonal interdental/Steinmann pin wiring is safe, expeditious, and effective in facilitating exposure of the distal internal carotid artery.

Paradigm Shift of Carotid Body Paraganglioma Surgical Technique from Caudocranial to Craniocaudal Dissection: Analysis of Recent Literature

“…29 Sometimes larger tumors may need mandibular subluxation, reserved for large tumors that usually extend cranially, advancing the vertical ramus of the mandible forward by 2 to 3 cm transforming the normal triangular shaped operative field into a rectangular one, widening its apex, thus providing additional space for safe exposure and control of the distal IcA. 30 carotid reconstruction done for grade III had 7.5% incidences of stroke, while due to IcA injury and thrombosis 0 to 16%. 11,31 Adequate anticoagulation is to be maintained or else clamping, ligation or reconstruction will cause cerebral ischemia.…”

Mandibular Subluxation for Distal Cervical Exposure of the Internal Carotid Artery

“…Exposure of the distal segment of the cervical ICA represents a challenge even for more experienced surgeons and may require ancillary maneuvers. The mobilization of the mandible as an adjuvant maneuver for this access can be achieved by mandibulotomy or mandibulectomy, procedures generally associated with a higher morbidity and prolonged surgery time, or by MS, which is a relatively safer, faster, and easier procedure 1,5,16–18,20,21 . However, it may be associated with TMJ dysfunction, usually temporary, 20 and injury to the facial arteries and vein 5,9,21 …”

“…Unilateral MS can be maintained with stainless steel wiring between the mandible and maxilla (which can be attached to the teeth, around the mandible, and around the alveoli in the maxilla) or through the use of pins in the mandible and maxilla, depending on the dental health of the patients 1,20 . The procedure lasts only 15 minutes, and the wires are removed immediately at the end of surgery 1,17 . This technique has been applied to patients with carotid body tumors and patients submitted to endarterectomy of the carotid artery in which the carotid bifurcation was at the level of C2 or above or the atheromatous plaque extended to within 2 cm of the base of the skull above the mandibular angle 1,17,20 .…”

“…In MS, the mandibular condyle should be positioned just beyond the articular eminence of the zygoma (Fig. 4) because further displacement may result in dislocation of the condyle into the infratemporal fossa 17 . Of note, MS produces a slight distortion of the local anatomy with displacement of the posterior belly of the digastric and hypoglossal nerve anteriorly and superiorly and medial rotation of the carotid bifurcation and ICA, 20 so care is recommended when dividing the muscle to avoid hypoglossal injury.…”

“…However, these maneuvers are associated with higher morbidities such as temporomandibular joint (TMJ) dysfunction, cranial nerve injury, infection of the surgical wound, and dental malocclusion, in addition to increasing the time of surgery and impairing postoperative recovery 1,17 . Among these maneuvers, MS is a relatively fast and ease procedure usually associated with a lower morbidity 17,20 …”