After longitudinal incision at the front edge of the sternocleidomastoid muscle (SCM), the incision was deepened through the platysma muscle, and the investing layer of the deep cervical fascia was opened on the anterior border of the SCM muscle. The anterior edge of the SCM muscle was mobilized, and the muscle was separated from the underlying vascular sheath by a sharp dissection on its medial border. By retracting the freed SCM muscle posteriorly, the carotid sheath was identified. The sheath was opened superior to the omohyoid muscle. The internal jugular vein was dissected along its medial border in the central part of the field and retracted posteriorly with the SCM muscle. The common facial vein was divided, as well as other medially coursing branches and the internal jugular vein was mobilized laterally. The ansa n. hypoglossi was pushed laterally. The common carotid artery (CCA) was isolated using sharp dissection before manipulation of the atherosclerotic bifurcation. The vagus nerve was identified and protected. The external carotid artery (ECA) was isolated just above the bifurcation. The internal carotid artery (ICA) was isolated next. Hypoglossal nerve was indentified in the distal part of ICA. Once the carotid bifurcation was exposed and Unfractionated Heparin (UFH) was administered (5000IU).
Interestingly according to the latest ESVS carotid and antithrombotic guideline there are no recommendations about the intraoperative anticoagulation during carotid cross clamping. There is only recommendation for the use of Unfractionated Heparin and Bivalirudin during open and endovascular arterial procedures, which is based on an expert consensus and one meta-analysis of small observational trials.
Source: Twine CP, Kakkos SK, Aboyans V, Baumgartner I, Behrendt CA, Bellmunt-Montoya S, et al. Editor’s Choice – European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on Antithrombotic Therapy for Vascular Diseases. Eur J Vasc Endovasc Surg. 2023;65(5):627-689.
