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Abstract
Bifurcation of the carotid artery at a cephalic location greatly increases the risk associated with carotid endarterectomy (CEA). Mandibular subluxation (MS) can improve access to the cephalic location; however, the benefits of MS remain unclear. The present study objectively assessed the efficacy of MS. MS was performed with only wire fixation of healthy teeth in four patients (Group A), with wire fixation reinforced by inserting Coltoflax® putty between healthy teeth in 17 patients (Group B), and with wiring between maxillary and mandibular screws reinforced by inserting Coltoflax® putty between the wires in five edentulous patients (Group C). Pre- and postoperative axial computed tomography angiography images at the level of the tip of the mastoid process were used to compare the following measurements: mastoid-mandible distance between the anterior margin of the mastoid process and posterior margin of the mandible; and mastoid-internal carotid artery-mandible (MIM) angle between the line connecting the anterior margin of the mastoid process and the center of the internal carotid artery, and the line connecting the posterior margin of the mandible and the center of the internal carotid artery. MS increased the overall mastoid–mandible distance by 5.7 ± 3.1 mm. The increase was significantly greater in Group B (6.7 ± 2.0 mm) than in Group A or C (4.0 ± 4.1 mm) (P=0.032). MS increased the overall MIM angle by 13.3 ± 7.9o. MS with the combination of wire with Coltoflax® putty offered the widest surgical corridor for CEA.
Highlights
Carotid endarterectomy (CEA) requires adequate exposure of the cephalic location of the internal carotid artery (ICA) for removal of the distal end of the plaque
The present study used computed tomography (CT) angiography to objectively assess the efficacy of Mandibular subluxation (MS) with three methods for CEA
The following characteristics on the pre- and postoperative axial CT angiography images at the level of the tip of the mastoid process were compared on the affected side: mastoid-mandible distance between the anterior margin of the mastoid process and posterior margin of the mandible (Figure 2A); and mastoid-ICA-mandible (MIM) angle created by the line connecting the anterior margin of the mastoid process and the center of the ICA, and the line connecting the posterior margin of the mandible and the center of the ICA (Figure 2B)
Summary
Carotid endarterectomy (CEA) requires adequate exposure of the cephalic location of the internal carotid artery (ICA) for removal of the distal end of the plaque. CEA becomes a high-risk procedure if the bifurcation of the carotid artery is located at a cephalic location [1]. In Japanese patients, the position of the carotid artery bifurcation is approximately one vertebral body higher than in patients in Western countries [2], so that adequate exposure of the ICA is more difficult to achieve. Mandibular subluxation (MS) for CEA has been proposed to access such a cephalic location of the bifurcation [3,4,5,6,7,8,9,10,11,12]. The present study used computed tomography (CT) angiography to objectively assess the efficacy of MS with three methods for CEA
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