Surgical access to the distal cervical segment of the internal carotid artery and to a high carotid bifurcation – integrative literature review and protocol proposal

Abstract

Several different maneuvers have been described for obtaining access to the distal cervical segment of the internal carotid artery or to a high carotid bifurcation. However there are different approaches to systematization of these techniques. The objective of this study is to review the techniques described and propose a practical protocol to support selection of the most appropriate technique for each case. The review is based on the results of database searches on PubMed Central, the Virtual Health Library (BVSalud), and SciELO for articles on the subject published in English or Portuguese from 1980 to 2021. Among the different maneuvers described, it appears reasonable that the first two steps should be to obtain access at the sternocleidomastoid muscle, followed by section or retraction of the digastric muscle posterior belly. If needed, temporary unilateral mandibular subluxation is an additional resource that is preferable to division of the styloid apparatus process, because of its lesser potential for morbidity. Even wider exposure can be obtained using mandibular osteotomies.

Is low carotid bifurcation determined by vertebral level always convenient for surgical approach?

“…Plaques resulting from atherosclerosis are typically found above the point of bifurcation in the carotid arteries (CB) [3]. Nevertheless, high-level carotid bifurcation (HCB) could lead to difficult surgical access during CEA to approach and treat this plaque because of restricted CB exposure [4,5]. In the presence of HCB, adjacent structures such as the hypoglossal nerve, which provides motor innervation to the tongue [6][7][8][9][10], as well as the marginal mandibular, recurrent laryngeal, and accessory nerves, and the sympathetic chain [1] and submandibular gland [2], could be injured during CEA.…”