Surgical Pitfalls in Carotid Endarterectomy: A New Step-By-Step Approach

Abstract

Carotid endarterectomy (CEA) is a surgical intervention that may prevent stroke in asymptomatic and symptomatic patients. Our aim was to examine the microsurgical anatomy of carotid artery and other related neurovascular structures to summarize the CEA that is currently applied in ideal conditions. The upper necks of 2 adult cadavers (4 sides) were dissected using ×3 to ×40 magnification. The common carotid artery, external carotid artery (ECA), and internal carotid artery were exposed and examined. The surgical steps of CEA were described using 3-D cadaveric photos and computed tomography angiographic pictures obtained with help of OsiriX imaging software program. Segregating certain neurovascular and muscular structures in the course of CEA significantly increased the exposure. The division of facial vein allowed for internal jugular vein to be mobilized more laterally and dividing the posterior belly of digastric muscle resulted in an additional dorsal exposure of almost 2 cm. Isolating the ansa cervicalis that pulls hypoglossal nerve inferiorly allowed hypoglossal nerve to be released safely medially. The locations of the ECA branches alter depending on their anatomical variations. The hypoglossal nerve, glossopharyngeal nerve, and accessory nerve pierce the fascia of the upper part of the carotid sheath and they are vulnerable to injury because of their distinct courses along the surgical route. Surgical exposure in CEA requires meticulous dissection and detailed knowledge of microsurgical anatomy of the neck region to avoid neurovascular injuries and to determine the necessary surgical maneuvers in cases with neurovascular variations.

Unusual Anterior Neck Swelling: Cervical Spinal Cord Schwannoma

“…To understand head and neck surgery and to perform systematic and safe excision of tumors, training in neuroanatomy of the neck region is essential. 17 18 19 20 A detailed knowledge of the complex topographic relationships between muscles, blood vessels, nerves, and lymph nodes will enable the surgeon to safely perform difficult and risky dissection in the head and neck region. In addition, a good knowledge of both anterior and posterior approaches—as well as their variations—to the neck region is crucial in choosing the most appropriate surgical method.…”

Optimal anatomical angle and distance for drilling in cervical oblique corpectomy: A surgical anatomical study

“…Apart from the belief that anterior cervical approaches generally have more complications than posterior approaches, the main reasons reported in the literature for the avoidance of the cervical oblique corpectomy are the additional surgical challenges, due to the probability of injury to the cervical sympathetic chain and vertebral artery (VA) being higher compared to other anterior procedures. [ 9 10 11 12 ]…”

Cervical Oblique Corpectomy: Revitalizing the Underused Surgical Approach With Step-By-Step Simulation in Cadavers

“…The main reason for this is probably the surgical technical difficulty of OC. In addition to the procedure's long learning curve, the risk of injury to the vertebral artery and cervical sympathetic trunk is the main difficulty of this challenging surgical approach 3,8,9,11–30 . Notwithstanding, it is a partial corpectomy and has the upsides of no graft transplantation or instrumentation needs and, hypothetically, the safeguarding of characteristic neck movements 3,7,23,25,31 .…”

“…In addition to the procedure's long learning curve, the risk of injury to the vertebral artery and cervical sympathetic trunk is the main difficulty of this challenging surgical approach. 3,8,9,[11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30] Notwithstanding, it is a partial corpectomy and has the upsides of no graft transplantation or instrumentation needs and, hypothetically, the safeguarding of characteristic neck movements. 3,7,23,25,31 This is an important advantage in terms of cost-effectiveness if OC can be frequently performed, but the surgical anatomy of OC should be thoroughly understood so that technical difficulties can be overcome.…”