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An Alternative Approach to Carotid Endarterectomy in the High Carotid Bifurcation
Ashley Farhat-Sabet1, Brittany O Aicher1, Besher Tolaymat1
1Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD.
Insights
A novel high transverse neck incision with subplatysmal flaps offers a safe and effective surgical approach for carotid endarterectomy (CEA) in patients with high carotid bifurcations (HCB), potentially avoiding more invasive techniques.
Area of Science:
- Vascular Surgery
- Surgical Techniques
- Cervical Anatomy
Background:
- High carotid bifurcation (HCB) poses surgical challenges for carotid endarterectomy (CEA) due to cranial neck anatomy.
- Carotid artery stenting (CAS) is a common alternative, but surgical options are sought.
- A high transverse neck incision with subplatysmal flaps is proposed as an alternative surgical exposure.
Purpose of the Study:
- To present a high transverse neck incision with subplatysmal flaps as an alternative surgical approach for CEA in patients with HCB.
- To evaluate the safety and efficacy of this technique.
Main Methods:
- Four patients with HCB underwent CEA using a high transverse neck incision and subplatysmal flap elevation.
- CEA was performed using a bovine pericardial patch.
- Preoperative imaging identified HCB location cranial to C3-4 vertebral interspace.
Main Results:
- All four patients successfully underwent CEA without mandibulotomy or hyoid bone resection.
- No perioperative complications or significant cranial nerve injuries occurred.
- 100% primary patency was observed with a mean follow-up of 160 days.
Conclusions:
- The high transverse incision with subplatysmal flaps is a safe and effective method for CEA in HCB patients.
- This approach is cosmetically preferable and may serve as an alternative to CAS.
- It facilitates CEA without requiring additional exposure techniques.
Background:
Surgical exposure of a high carotid bifurcation (HCB) for carotid endarterectomy (CEA) can be technically challenging due to the presence of bony structures in the most cranial portion of the neck and is associated with significant morbidity making carotid artery stenting (CAS) a common alternative. However, a high transverse neck incision with subplatysmal flaps facilitates CEA in these patients without additional exposure techniques. We present a high transverse neck incision with subplatysmal flaps as an alternative to the standard surgical exposure of the carotid bifurcation to facilitate CEA in patients with HCB.
Methods:
Four patients with carotid bifurcations located cranial to the C3-4 vertebral interspace (identified on preoperative imaging) requiring intervention underwent CEA using a high transverse neck incision through an existing skin crease with subplatysmal flap elevation. CEA was performed in a standard fashion with bovine pericardial patch.
Results:
Two male and 2 female patients with an average age of 65 years successfully underwent CEA using this incision. One patient underwent concurrent carotid body tumor excision. None of the patients required mandibulotomy or hyoid bone resection. Two patients required division of the posterior belly of the digastric muscle. There were no perioperative complications. Primary patency was 100% in the 4 patients with surveillance studies, and mean follow-up of 160 days (range 54-369 days). There were no significant cranial nerve injuries. No patient required conversion to an endovascular procedure due to inaccessibility of the lesion or subsequent interventions for incomplete endarterectomy.
Conclusions:
A high transverse incision with subplatysmal flaps is a safe, effective, and cosmetically preferable surgical approach in patients with HCB requiring carotid artery intervention and may be an alternative to CAS.
