An Alternative Approach to Carotid Endarterectomy in the High Carotid Bifurcation

Abstract

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. 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. Two male and 2 female patients with an average age of 65years 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 160days (range 54-369days). 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. 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.