Exposure of the Carotid Bifurcation
Introduction
Carotid endarterectomy is one of the most frequently performed vascular operations. The vast majority of these procedures are for atherosclerosis at the bifurcation of the common carotid artery, which lies within the anterior triangle of the neck, usually at the upper border of the thyroid cartilage (Fig. 32-1, A). The key anatomic boundaries are the sternocleidomastoid muscle, the midline, and the mandible (Fig. 32-1, B).
Carotid Endarterectomy
The procedure begins with proper positioning of the patient, with the neck extended and turned toward the opposite side. The incision can be made along the anterior border of the sternocleidomastoid muscle (SCM) or transversely (obliquely) in a skin crease overlying the carotid bifurcation (Fig. 32-1, B). The bifurcation can easily be located with duplex ultrasound. The platysma muscle is then divided, exposing the deep cervical fascia (Fig. 32-1, C).
Surgical Principles
The external jugular vein and greater auricular nerve lie in this plane; the vein can be ligated, but the nerve must be preserved to avoid numbness of the ear lobe (Fig. 32-2, A).
Next, two key steps are necessary to expose the carotid bifurcation. The first is mobilization of the anterior border of the SCM, which is invested within two layers of the deep cervical fascia (Fig. 32-2, B). If a transversely oriented incision is used, this requires creation of subplatysmal flaps, both cephalad and caudad, on the plane of the anterior SCM fascial layer.
