Procedures

Carotid Endarterectomy and Patch Plasty (with Optional Intraluminal Shunting)

A carotid endarterectomy may be needed if one or both carotid arteries become narrowed by a build-up of fatty/calcified deposits (plaque). In symptomatic stenosis - if the patient has suffered a stroke or TIA - carotid endarterectomy may be helpful if the stenosis is over 50%. In asymptomatic stenosis, carotid endarterectomy can be helpful to reduce stroke risk if the narrowing is 70% or greater.

All Steps in Detail

Step 1: Skin incision and exposure

  1. Longitudinal incision at the edge of the sternocleidomastoid muscle
    Alternative: Transverse incision
  2. Upper border of the exposure: digastric muscle, lower border: omohyoid muscle
  3. Ligation of the facial vein and identification of the carotid bifurcation
  4. Identification of the external carotid artery (ECA) and the inferior thyroid artery (vessel loop each)
  5. Exposure of the common carotid artery (CCA), umbilical tape and tourniquet (cave: vagal nerve)
  6. Exposure of the internal carotid artery (ICA) on the anterior side, no vessel loop (especially in symptomatic patients, clamping of the CCA before dissection of the ICA is recommended)
  7. Optional: identification of the hypoglossal nerve
  8. No/minimal touch of the site of the stenosis

Step 2: Conventional endarterectomy

  1. Clamping of the ICA, the CCA and the ECA (memorize: ICE)
  2. Longitudinal incision from the distal CCA into the proximal ICA
  3. Optional: shunt insertion
    1. Shunt insertion in the CCA
    2. Flushing, removal from air bubbles
    3. Open the distal ICA clamp
    4. Shunt insertion in the ICA under back-bleeding conditions (cave: air bubbles and distal dissection by the shunt!)
  4. Local open endarterectomy under visual control
  5. Control of the distal end of endarterectomy, tacking sutures if needed (6/0)

Step 3: Patch plasty of the carotid bifurcation

  1. Primary closure only in highly selected cases
  2. Patch plasty with bovine pericardium patch, Dacron or vein
  3. Start parachute running suture at cranial end, 3 stitches from the incision end, inside-out ICA
  4. Shunt removal and flushing of the CCA, the ECA and the ICA
  5. Declamping of the ECA first, CCA second and ICA third (after 10 heart beats) (memorize ECI)
  6. Quality control with on table duplex sonography (completion angiography optional)

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Control of educational objectives (tutor and trainee)

  1. Clearcut arteriotomy, extending beyond the level of the disease proximally and distally
  2. Declamping in correct sequence
  3. No excessive bleeding, narrowing or kinking of the reconstruction
  4. Outside aspect: knot and suture tightness, patch width, eversion, suture of ACC and ACI corner
  5. Inside aspect: Suture corner of ACC and ACI, eversion, patch width

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Courses Teaching this Procedure

European Vascular Master Class 2026

Jan 21, 2026
 - 
Jan 23, 2026
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Simulators Used for this Procedure

Carotid Simulator

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