External carotid endarterectomy under direct vision

At the conclusion of standard carotid endarterectomy in 50 consecutive patients, we examined flow in the external carotid artery using a continuous-wave Doppler probe. In two patients (4 percent), flow was absent in the distal external carotid artery. In both patients, opening the external carotid artery through a separate incision revealed an obstructing intimal flap that was removed easily under direct vision, and external carotid endarterectomy was accomplished without interrupting flow through the internal carotid artery. This simple manuever allows for salvage of external carotid arteries that are occluded during standard blinded external carotid endarterectomy.