Distal Cervical Internal Carotid Artery Research Articles

Isolated internal carotid artery dissection after a motorcycle accident: A case report

Extra cranial carotid artery dissection is one of the most important complications associated with blunt head and neck trauma. It is a major cause of ischemic stroke in young adults. We report a case of internal carotid artery dissection which caused transient hemiparesis, horizontal gaze to right and anisocoria in a 19-year-old male motorcyclist involved in a collision. Unenhanced brain computed tomography scan showed well defined infarction in the right frontotemporoparietal area. Digital subtraction angiography showed complete occlusion of the proximal cervical right internal carotid artery. Moreover, intimal dissection was observed in distal cervical left internal carotid artery which did not limit blood flow to the brain. A stent was placed at the site of dissection in the left internal carotid artery. Intravenous heparin was commenced to avoid further thrombosis. He was discharged home 40 days after the accident with oral anticoagulation. Extra cranial carotid artery dissection is a rare condition which may happen after a non-significant neck trauma. Accordingly, the diagnosis of a cervical vascular dissection requires strong clinical suspicion

Correlation between intravascular pressure gradients and ultrasound velocities in carotid artery stenosis: An exploratory study.

Grading of carotid stenosis is routinely performed with non-invasive techniques, such as carotid ultrasound (CUS) and computerized tomography angiography (CTA), which have limitations in grading definition. Moreover, the actual hemodynamic impact of a stenosis remains poorly defined. Preliminary studies explored the application of the resting full-cycle ratio (RFR), measured with pressure wire (PW), but the correlation between RFR and morphological/hemodynamic parameters is still undefined. This study aims to test the correlation between RFR and CUS-CTA-DSA based degree of stenosis, to define the suitability of RFR as carotid stenosis index. We included patients with symptomatic carotid stenosis receiving carotid artery stenting (CAS), between November 2022 and May 2023. We performed CUS and PW measurements before and after stenting, at four different sites (trans-lesion, distal cervical, petrous and supraclinoid internal carotid artery [ICA] segments). We compared CUS and PW parameters by Pearson's or Spearman test for continuous variables. Among 15 patients included the mean stenosis degree was 81.3%. Trans-lesion RFR was significantly higher than other sites (0.72 ± 0.2 trans-lesion vs. 0.69 ± 0.18 distal cervical ICA vs. 0.66 ± 0.2 petrous ICA vs. 0.6 ± 0.2 intracranial ICA, p < 0.05). All RFR values significantly increased after treatment; the highest relative increase was registered at stenosis site (0.72 ± 0.2 pre-stent vs. 1.01 ± 0.1 post-stent, p < 0.01). Trans-lesion RFR was significantly associated with the CTA and DSA stenosis degree and CUS measurements. Pressure wire in carotid artery stenosis seems safe and suitable. Resting full-cycle ratio has a significant correlation with CUS values and stenosis degree and might be used as carotid stenosis index during CAS.

Endovascular straightening of the internal carotid artery during mechanical thrombectomy: The "tightrope technique".

Mechanical thrombectomy is a standard treatment for acute stroke, but it can be technically challenging in elderly patients with difficult vascular anatomy. To overcome this issue, we propose a new endovascular approach called the "tightrope" technique. This technique uses a stiff guidewire and a standard angiographic catheter to straighten the internal carotid artery (ICA) tortuosity, allowing the guiding catheter to be positioned next to the intracranial level. We retrospectively evaluated all the procedures in which the "tightrope" technique was used. This approach involves advancing a 0.035″ Advantage stiff guidewire and a standard 4 Fr angiographic catheter through the vascular tortuosity. The catheter is twisted over the guide wire in a clockwise direction, gaining tension that gradually straightens the vascular axis, allowing the guiding catheter to pass up to the distal ICA. Between June 2022 and March 2023, we successfully performed consecutive mechanical thrombectomy procedures using the tightrope technique in 11 patients with highly tortuous ICA segments. In all cases, we were able to safely advance the catheter system up to the distal cervical ICA. Although our study included a small cohort of patients, the "tightrope" technique proved to be successful in all patients, allowing for safe advancement of the guiding catheter toward extremely tortuous anatomy. However, further validation in a larger patient population is necessary to determine the technique's effectiveness and safety profile.

Cadaver investigation of the usefulness of the transstyloid diaphragm approach for high-position plaque carotid endarterectomy

ObjectivesPatients sometimes present with high cervical internal carotid artery (ICA) stenosis. This study demonstrates the usefulness of the transstyloid approach to expose the distal ICA by dissection of the styloid diaphragm covering the distal cervical ICA for carotid endarterectomy (CEA). In particular, the possible exposure length achieved by this approach was investigated using cadaveric heads. MethodsThe procedure of the transstyloid diaphragm approach was confirmed in 10 cadaveric heads (20 sides). After the carotid triangle was opened, both the posterior belly of the digastric muscle (PBDM) and the stylohyoid muscle could be divided. Then, the carotid sheath was dissected, and the glossopharyngeal nerve was identified crossing over the distal ICA. The revealed length of the ICA was measured with or without dissection of both the PBDM and the stylohyoid muscle. The specimens were dissected under the surgical microscope. ResultsThe transstyloid diaphragm approach was achieved successfully in all specimens. The revealed lengths of the ICA with and without dissection of the styloid diaphragm were 53.7 ± 5.9 mm and 38.8 ± 2.9 mm (mean ± standard deviation), respectively. Therefore, the revealed length of the distal ICA was 14.9 ± 4.5 mm greater using the transstyloid diaphragm approach compared to the regular CEA approach. ConclusionsMore of the ICA can be revealed by dissection of both the PBDM and the stylohyoid muscle. The transstyloid diaphragm approach might be helpful to reveal the distal ICA in cases of high cervical ICA stenosis.

The AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Extracranial Cerebrovascular System.

The AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Extracranial Cerebrovascular System.

Stent-Assisted Coiling of a Sidewall Aneurysm of the Distal Middle Cerebral Artery: 2-Dimensional Operative Video.

Sidewall aneurysm treatment often requires complex management strategies. These can include advanced clipping techniques or stent-assisted coiling techniques. Endovascular coiling alone has been associated with high recurrence rates and is often not feasible.1-4 Flow-diversion embolization has recently become a standard of care for many aneurysms, demonstrating high occlusion rates.4,5 However, the third generation of coil-assist stents can be delivered with 0.0165" microcatheters, being an ideal adjunct to manage this group of aneurysms in more distal locations. In this video, a 16-yr-old teenager with Parry-Romberg syndrome and congenital adrenal hyperplasia had an incidental finding of a 6.5-mm sidewall aneurysm arising off the angular branch of the left middle cerebral artery, found during the work-up of complex partial seizures. The patient consented to the procedure. Due to his young age and aneurysm size, a decision was made to treat the aneurysm through an endovascular approach. Under general anesthesia, a transfemoral approach was carried out using a 6-French short sheath. A 6-French guiding catheter was left in the distal cervical left internal carotid artery; a 0.0165" microcatheter was used to first deploy a 3.0×15 mm Neuroform Atlas stent, completely covering the length of the aneurysm. Then, the stent was traversed with the microcatheter to coil the aneurysm. Follow-up cerebral angiogram confirmed complete occlusion of the aneurysm.

Biplane Fluoroscopic-Guided Balloon Rhizotomy for Trigeminal Neuralgia: A Technical Note.

The classic percutaneous technique used to cannulate the foramen ovale for the treatment of trigeminal neuralgia can place important anatomic structures, such as the distal cervical internal carotid artery, at risk. To use fixed anatomic landmarks to safely and reliably locate the foramen ovale on anteroposterior (AP) fluoroscopy. Locating the foramen ovale was initially tested using AP fluoroscopy on cadaveric skulls in the neurosurgical simulation lab. Fluoroscopic landmarks were identified and utilized to assist in successfully locating the foramen ovale during percutaneous balloon rhizotomy procedures in patients with trigeminal neuralgia. This technique has been successfully used in multiple patients. In this report, we describe our technique in detail. The AP fluoroscopy is directed laterally in the coronal plane until a line drawn inferiorly from the lateral orbital rim bisects the inner concavity of the mandibular angle. Fluoroscopy is then directed inferiorly until the top of the petrous ridge bisects the mandibular ramus. The foramen ovale will come into view within the window between the mandibular ramus and hard palate. Two case illustrations are provided. Balloon rhizotomy is a commonly used treatment option for trigeminal neuralgia. Direct visualization of the foramen ovale can reliably be achieved on AP fluoroscopy using specific anatomic landmarks. This technique can be utilized to increase the accuracy and safety of the procedure.

Emergency carotid artery revascularization using Casper-RX stent: A single-center experience.

Casper-RX (MicroVention, Aliso Viejo, California, USA) is a dual-layer closed cell stent recently introduced as a carotid artery revascularization device. Although its effectiveness and safety has been proved in elective cases, there are contradictive results regarding its patency in emergency settings. The purpose of the study is to present our single-center experience with the Casper-RX stent in the emergency interventions. Consecutive patients who underwent emergency carotid artery stenting using Casper-RX system with or without additional intracranial thrombectomy between August 2016 and June 2019 at our institution were included. Primary end point was the short-term patency of the carotid stents evaluated before hospital discharge by use of Doppler ultrasonography. Twenty-nine procedures performed on 28 patients were included in the study. All stents were patent on final angiograms. Acute stent occlusion was observed only in one case (3.4%) with a spontaneous cervical internal carotid artery dissection the day after the procedure. In 26 (89.6%) cases, an additional intracranial thrombectomy was performed with a successful recanalization rate of 96.1%. Seven adverse events occurred peri-/post-procedural: two cases (6.9%) with iatrogenic dissection of distal cervical internal carotid artery during intracranial thrombectomy, two parenchymal hematoma type 2 (6.8%), and three patients (10.3%) developed massive infarction. This study supports the safety and efficacy of the Casper-RX stent in emergency endovascular carotid artery revascularization procedures.

Abstract WMP40: Cervical Internal Carotid Artery Tortuosity as a Marker of Non-Atherosclerotic Aging: Results From the Northern Manhattan Study (NOMAS)

Background: Cervical internal carotid artery (ICA) tortuosity has been associated with vascular risk and stroke as well as genetic disorders related to abnormal extracellular matrix remodeling. It is plausible that dystrophic or aberrant arterial remodeling may therefore relate to cervical ICA tortuosity. We hypothesized that cervical ICA tortuosity relates to carotid dilatation, but not to traditional ultrasound (US) markers of atherosclerosis. Methods: Subjects of the NOMAS with available time-of-flight MRA were included in our study. Cervical ICA tortuosity was defined as a bend in the distal cervical ICA of &gt; 90° as seen on MRA. We excluded subjects with &lt; 5 cm of the cervical ICA visualized. Distensibility was calculated as the percentage excursion of the right CCA diastolic diameter during systole, which was assessed by high-resolution B-mode US of the right common carotid artery (CCA). We used multivariable logistic regression analyses to estimate odds ratios for the association of cervical ICA tortuosity and Doppler measures of carotid wall aging. Results: We visualized cervical ICA tortuosity in 468 NOMAS participants (mean age 64±8 years, 70% women, 70% Hispanic). It was present in 23% of subjects. In unadjusted models, cervical ICA tortuosity was more common in women (OR 2.34, 95% CI 1.34-4.11), Hispanics (OR 1.85, 95%CI 1.06-3.25) and those with higher diastolic blood pressures (OR per mm Hg 1.04, 95%CI 1.01-1.06), and less common among smokers (OR 0.23, 95%CI 0.07-0.78). In models adjusted for demographic and vascular risks, right CCA tortuosity was associated with ipsilateral larger CCA DD (OR 1.42, 95%CI 1.02-1.96) and borderline associated with lower distensibility (OR 0.94, 95%CI 0.87-1.01, P=0.06) but not with ipsilateral ICA IMT (OR 0.26, 95%CI 0.14-4.77), number of plaques (OR 1.08, 95%CI 0.76-1.53), maximum plaque thickness (OR 0.96, 95%CI 0.73-1.27), or plaque area (1.00, 95%CI 0.97-1.05). Conclusions: Cervical ICA tortuosity associates with ipsilateral cervical ICA dilatation and lower distensibility, but not with traditional US markers of atherosclerosis. The association with diastolic blood pressure suggests a role of steady, rather than pulsatile, hemodynamics in aberrant cervical ICA remodeling.

Bi-Plane Fluoroscopic-Guided Balloon Rhizotomy for Trigeminal Neuralgia: A Technical Note

Abstract INTRODUCTION The classic partially blinded percutaneous technique using external landmarks to cannulate the foramen ovale for the treatment of trigeminal neuralgia can place important anatomical structures, such as the distal cervical internal carotid artery, at risk. We have developed a new technique in which we use anteroposterior fluoroscopy to reliably locate the foramen ovale and thus make it safer and easier to cannulate. METHODS Locating foramen ovale was initially tested using anteroposterior fluoroscopy on cadaveric skulls in the neurosurgical simulation lab. Fluoroscopic landmarks were identified and utilized to assist in successfully locating the foramen ovale during percutaneous balloon rhizotomy procedures performed in multiple patients with trigeminal neuralgia. This technique was successfully used in multiple patients at our institution without any immediate complications except for one cheek hematoma. In this report, we describe our technique in detail. RESULTS The AP fluoroscopy is directed laterally in the coronal plane until a line drawn inferiorly from the lateral orbital rim bisects the inner concavity of the mandibular angle. Fluoroscopy is then directed inferiorly until the top of the petrous ridge bisects the mandibular ramus. The foramen ovale will come into view within the window between the mandibular ramus and hard palate. Two case illustrations are provided CONCLUSION Balloon rhizotomy is a commonly used treatment option for trigeminal neuralgia. Direct visualization of the foramen ovale can reliably be achieved on AP fluoroscopy using specific anatomic landmarks. This technique can be utilized to increase the accuracy and safety of the procedure.

Navien catheter experience in neuroendovascular interventions.

Purpose Advancements in catheter technology have allowed for greater flexibility and trackability. We report 265 consecutive, single-center neurointerventional cases using the Navien guide catheter. Materials and methods Retrospective analysis was performed of consecutive intracranial endovascular procedures utilizing the Navien catheter. Data collected included procedure type, catheters, guide catheter position, cervical access artery tortuosity grade and complications. Results The 5 French catheter was used in 130 cases. The 6 French catheter was used in 135 cases. Access was via the internal carotid artery in 204, external carotid artery in 10, and vertebral artery in 51 cases. Catheter tip position was in the petrous segment of the internal carotid artery in 36.6% (97/265), distal cervical internal carotid artery in 13.9% (37/265), cavernous internal carotid artery in 10.2% (27/265), proximal or mid cervical internal carotid artery in 5.6% (15/265), supraclinoid internal carotid artery in 0.8% (2/265), and intradural vertebral artery in 0.8% (2/265) of cases. Catheter position was not determined in 18.9% (50/265) of cases. Proximal vessel tortuosity (grade B or C) was present in 98 cases (37%), and the catheter was tracked distal to the tortuosity in 93% (91/98) of these cases. The overall success rate without catheter complication was 97% (258/265). The Navien was replaced by another catheter in 1.9% (5/265) of cases. There was one cervical artery dissection (0.4%) and one severe vasospasm (0.4%) necessitating Navien removal. Conclusions The Navien guide catheter provided distal access support for neuroendovascular interventions in nearly all cases, including cases with proximal artery tortuosity, with a low rate of catheter-related complications.

E-050 Navigation of a Distal Cerebral Embolic Protection Device through Significant Vascular Tortuosity with a Novel Rapid Exchange Catheter System during Carotid Artery Stenting

IntroductionCarotid stenosis is a prevalent cause of ischemic cerebrovascular disease. Carotid endarterectomy and carotid artery stenting (CAS) have both been shown to provide effective and durable reductions in the risk...

In-Room Assessment of Cerebral Blood Volume for Guidance during Intra-Arterial Thrombolytic Therapy

In acute ischemic stroke, the ability to estimate the penumbra and infarction core ratio helps to triage those who will potentially benefit from thrombolytic therapies. Flat-panel post-contrast DynaCT imaging can provide both vasculature and parenchymal blood volume within the angio room to monitor hemodynamic changes during the endovascular procedures. We report on an 80-year-old woman who suffered from an acute occlusion of the right distal cervical internal carotid artery. She was transferred to the angio room where in-room post-contrast flat-panel DynaCT imaging (syngo Neuro PBV IR) was performed to access the ischemic tissue, followed by successful mechanical thrombolytic therapy.

A case of traumatic internal carotid artery aneurysm secondary to carotid shunting

The use of a carotid shunt is a well-accepted method for the prevention of cerebral ischemia during carotid surgery. Although carotid surgeons are familiar with the risks associated with shunt use, few reports have been published detailing the nature, incidence, or severity of shunt-related complications. We report on a patient with dilatation of the distal cervical internal carotid artery at the site of Pruitt-Inahara (LeMaitre Vascular, Inc. Burlington, Mass) shunt balloon inflation. To our knowledge, this complication of shunting during carotid endarterectomy has not been previously described.

Sixty-Four-Section Multidetector CT Angiography of Carotid Arteries: A Systematic Analysis of Image Quality and Artifacts

Sixty-four-section CT scanners have recently been introduced for vascular imaging. Before such scanners reach widespread use, scanning protocol should be optimized and image quality assessed. The goals of this study were to systematically measure image quality and determine the prevalence of various types of artifacts produced by a 64-section scanner. We retrospectively reviewed CT angiography (CTA) scans obtained on a 64-section CT scanner in 100 consecutive patients presenting to the emergency department during a 2-month period with a suspected acute cerebrovascular event. We evaluated scan quality by using 2 different methods: First, we quantitatively assessed arterial opacification by measuring attenuation values in 9 arterial segments from the aortic arch to the distal cervical internal carotid artery, by using a threshold of 150 HU as an indicator of good opacification. Second, we assessed image contrast between arteries and veins by measuring attenuation within venous segments and recording the number of artery-vein-segment pairs in which the attenuation difference was <or=50 HU. In addition, we recorded the prevalence of the following artifacts: metallic hardware streak, contrast material streak from slow-flowing contrast material in adjacent large veins, streak artifacts from shoulders, contrast material reflux into veins of the neck, motion artifacts, and artifacts causing misrepresentation of flow dynamics simulating arterial dissection or occlusion. These results were compared with those of a historical control group of 113 patients from our institution who were imaged with the same technical parameters on a 16-section CT scanner. The quantitative assessment of arterial opacification showed that 854 of 885 analyzed arterial segments (96.5%) had good opacification (ie, attenuation values >150 HU). Image contrast between artery and vein segments was also good, with 714 of 763 analyzable segment pairs (85.6%) having >50 HU difference. Artifacts obscuring arterial evaluation included streak from contrast material in the subclavian/brachiocephalic vein (32% of patients), attenuation of the x-ray beam between the shoulders (28%), beam-hardening from metallic hardware (26%), and contrast material reflux into neck veins (16%). The most clinically relevant artifacts were flow artifacts, mimicking dissection or vascular occlusion; they were seen in 14% of patients and likely are related to the rapid data acquisition for CTA on 64-section scanners (compared with the circulation of contrast material in the cervical arteries). None of the patients in our historical control group who underwent 16-section CT had flow artifacts on their CTA studies; the incidence of the other types of artifacts in this group was similar to that in patients imaged with 64-section CT. The 64-section CTA imaging protocol for carotid arteries yields high-quality studies in >95% of cases.

Persistent primitive hypoglossal artery with retrograde flow from the vertebrobasilar system: a case report

The persistent primitive hypoglossal artery (PPHA) is one of the pairs of arterial connections that exist in the human embryo between the developing anterior and posterior circulation. Normally the PPHA arises from the cervical internal carotid artery (ICA) and passes through the hypoglossal canal to join the caudal basilar artery (BA). In most cases the vertebral arteries (VA) are either hypoplastic or aplastic and the posterior communicating arteries (PComA) are absent; thus, the main supply to the posterior circulation comes from the internal carotid via the PPHA in an antegrade fashion. Atherosclerotic plaques in the ICA and PPHA present with ischemic symptoms of both the carotid and vertebrobasilar systems. We report a case of a 53-year-old female who presented with a transient episode of left lower extremity numbness and weakness. Work-up with computed tomography (CT) and magnetic resonance imaging (MRI) showed a small watershed infarct in the right middle cerebral artery (MCA)/posterior cerebral artery (PCA) territory. Diagnostic angiography revealed severe proximal stenosis of the cervical ICA and presence of a PPHA just above the stenosis with retrograde filling from the vertebrobasilar junction to the distal cervical ICA. The patient underwent a carotid endarterectomy with intraoperative EEG monitoring. Intraoperative blood flow measurements were made before and after endarterectomy showing evidence of reversal of blood flow to a normal antegrade fashion. The postoperative angiogram showed resolution of the right ICA stenosis and persistence of the PHA. To our knowledge this is the first case report of a PPHA exhibiting reversal of blood flow from the posterior into the anterior circulation. Awareness of this embryological anomaly and its interaction with acquired atherosclerotic disease will minimize misinterpretation of vascular diagnostic studies.

Mandibular Subluxation for Distal Cervical Exposure of the Internal Carotid Artery

Surgical access to the distal segment of the cervical internal carotid artery (ICA) is a challenge because of the limited exposure imposed by bony structures and concern regarding cranial nerve and major vasculature injury. Our objective is to quantify the additional exposure of the distal cervical ICA obtained with mandibular subluxation (MS) compared with maneuvers that do not mobilize the mandible. Thirty dissections of the cervical ICA and common carotid artery bifurcation were performed on fresh cadavers. The length of the ICA exposure was measured from the carotid bifurcation to the most distally exposed ICA after sectioning the posterior belly of the digastric and stylohyoid muscles, removal of the styloid process, and MS. After MS, a 5.52 +/- 1.00 cm mean exposure of the cervical ICA was obtained. Comparison between the second and third measures revealed an average additional exposure of the ICA of 0.77 cm, corresponding to an additional 16.2% (P < .001). Neck length, sex, and age showed no correlation with the ICA exposure. MS provided an additional exposure of the distal segment of the cervical ICA and may be useful in selected cases to improve access. However, staged maneuvers should be used, and the need for MS depends on the level and extension of the lesion.

A report of two cases with dolichosegmental intracranial arteries as a new feature of PHACES syndrome

We describe two previously unreported cases with complete or incomplete expression of PHACES syndrome, a rare congenital syndromal pediatric disorder, which is characterized by posterior cranial fossa malformations, large facial hemangiomas, arterial anomalies, coarctation of the aorta and cardiac defects, abnormalities of the eye, sternal and supraabdominal raphe defects. These two children exhibited a feature not reviewed extensively in the literature, namely, segmental elongation and dilatation of intracranial arteries associated with intracranial occlusive arterial disease, predominantly on the anterior division of the internal carotid artery (ICA) and on the P2 segment of the posterior cerebral artery. This dolichoectasia was found at the distal cervical internal carotid artery, the intradural segment of the ICA before the division, the trigeminal artery, and the posterior division of the ICA. We presume that the different forms of arterial involvement in PHACES syndrome (arterial stenoses, segmental agenesis of vessels, and the dolichoectasia described in this study) constitute a spectrum of angiogenetic dysfunctions related to an embryonic event involving several cephalic neural crest segments of the dorsal aorta.

Combined open and endovascular treatment of a saccular aneurysm and redundant loop of the internal carotid artery

We report the unusual case of a woman with a saccular aneurysm of the distal cervical internal carotid artery arising just distal to a kink and a 360 degrees redundant loop. The retromandibular position of the aneurysm would have mandated a complex surgical procedure. A purely endovascular approach was not possible owing to the difficulty to pass any kind of device beyond the redundant loop. A hybrid approach, in which the kink was surgically straightened and the saccular aneurysm coiled after stenting of its orifice, was therefore used to treat this challenging case. A review of the literature supporting this approach is discussed.

Exposure of the Cervical Internal Carotid Artery: Surgical Steps to the Cranial Base and Morphometric Study

Several studies have reported on approaches to increase exposure of the distal cervical internal carotid artery (ICA), but these studies have neither systematically addressed the anatomic aspects nor quantified the additional exposure of each maneuver. We describe surgical steps to expose the ICA region, quantify the additional exposure of each operative step, and discuss ways to minimize surgical morbidity. The ICA was exposed in 10 formalin-fixed cadaveric heads using the following four steps: 1) anterior sternocleidomastoid approach, 2) retroparotid dissection and division of the digastric muscle, 3) section of the styloid apparatus, and 4) mandibulotomy. After completion of each step, the most distal level of ICA exposure was marked with a hemoclip and segment lengths were measured between each clip. Sectioning of the digastric muscle and sectioning of the styloid apparatus provided the most significant exposure of the ICA (14.15 and 15.08 mm, respectively) with minimal risks. Mandibulotomy added 10.20 mm in length and 20.65 degrees in width, but is a maneuver that must be weighed against the heightened risk of morbidity. Surgical exposure of the distal cervical ICA is associated with relatively high morbidity that increases with higher levels of exposure. Staged maneuvers have been shown to increase ICA exposure, especially in our systematic approach. The number of steps required varies depending on the level of lesion. Complete understanding of the surgical anatomy is essential to minimize surgical morbidity and to develop surgical expertise.