Thanks for the opportunity. This is my first Mary course and I think it's a marvelous thing to have this type of resident training course. So I'd just like to go over a few things about carotid surgery this morning. First show of hands, how many of your programs do a significant proportion of the carotid artery surgery at your institution? So a few. If you look at the national statistics, it's about 4% of the carotid endarterectomies in the country that are done by neurosurgeons. I think this is an enormous area of potential growth for us. And I think it's important for a few reasons. One, it's a very common operation. There are good data to support its efficacy. I think as more and more data come in in regards to angioplasty and stenting versus endarterectomy, it looks like low-risk surgery is still better than low-risk endovascular treatment for carotid disease. And I suspect that's going to continue to be the case. And I think this is a surgery that really gives residents a lot of experience in suturing, you know, manipulating vascular tissue, et cetera, et cetera. So I would hope neurosurgery could get more involved with treating carotid artery disease. And I think we can do that through alliances with our stroke neurology folks. A couple of things before we start the video. One, because I do this surgery without a microscope, with loops, the video is dependent on a resident videographer kind of moving around. And so I apologize ahead of time for those shots where my big hands are in the way. We tried to edit this so it's reasonable. But it's not quite the same as when you're doing a video through a microscope. A couple of other things. I do almost all my carotids awake with regional block transverse incision. They're all on aspirin and Plavix before the surgery and for six weeks afterwards. I think a little bit of pre-op prep for the patient who's going to have an awake operation is very important that, you know, you need to kind of take them through all the steps that they're going to run into. One other thing I found out, if you want to do these cases awake, do not sedate the patient. Somebody who's perfectly awake and interactive is much easier to deal with than someone who's gotten a little bit of sedation and starts out confused. And especially the older folks who have this operation, sedation I think in general is a bad idea. If at any point you have a question, please speak up. And you will have to speak up because with this interrogation light in my eyes, it's hard to see any hands. So let's get started. Okay, so this is a patient with a symptomatic critical right internal carotid artery stenosis. And what you see us doing here is marking out the posterior border of the sternocleidomastoid muscle. I usually do my own blocks. And I just use a half percent lidocaine with epinephrine and a large volume superficial block. And I usually put in 30 cc's or so. And you can do it very quickly. The hand contralateral to the surgery gets one of these high-tech monitoring devices. We buy these at the grocery store for $2.50 and then sell them as a medical device for $1,000. It's really good. But this gives you a way of checking motor response during the procedure. So right before the operation, I usually put a little extra lidocaine in the linear incision. And this is in a skin crease in the neck for cosmetic purposes. And so you see the incision. And then just a couple of self-retaining retractors, Wheatlander retractors. And I'll do almost all of the superficial decision with the Bovee knife. And that really helps with the bleeding. Someone's on aspirin and Plavix. You have to be pretty meticulous about that. And we're now down to the carotid sheath. So we've gone through the subcutaneous tissues. We've gone through the platysma, along the border of the sternocleidomastoid muscle. Sternocleidomastoid muscle is retracted laterally. And then once you get to the sheath, it's good to inject a little extra lidocaine. And so what you see here, I'm trying to demonstrate, is this is the common facial vein. And in a number of cases, the hypoglossal nerve will be right under that vein. So you have to be careful to make sure that when you take the vein, you don't injure the nerve. And I usually use Ligaclips. You can tie it. You can bipolar it. I think the Ligaclips are fast and secure and a nice way to do it. So now that the common facial vein has been divided, we're going to want to open up the sheath. And what you'll see here, we're just dissecting in the carotid sheath now. You want to find the common carotid artery. So we're coming up along the lateral side of the carotid. So the common carotid's down here, internal's going to be going up here. This person had a bifurcation at about C2-3. So this is a high bifurcation case. And one of the things you want to make sure you do is get enough distal carotid exposure. And I'll show you some tricks to do that in a minute. What we're doing is just getting a little bit of the external exposed. So now we're going to replace our retractors. These are blunt-toothed kneed Wheatlanders so that you can bend them down into the incision. And then this is a cloward retractor, an old cloward retractor. And they have these very nice smooth blades of varying lengths and widths that you can fit in. The upper blade goes right over the hypoglossal and this one goes on the omahyoid muscle. And you can now get very good, if I get my hand out of the way, you can see it, inferior superior exposure. Here's the hypoglossal, here's the ansa. And you want to come up lateral to the hypoglossal nerve to get your distal exposure. That's a little artery to the sternocleidomastoid muscle that's being coagulated and divided. And so the dissection's gonna, the hypoglossal will curve up this way, and you need to come out lateral to that. I usually put a little extra lidocaine in at this point as you're manipulating the vessel. A lot of times people, even with a very good block, they're going to feel sympathetic pain, they'll complain of pain in their neck or their teeth, and a little bit of extra lidocaine will stop that. So, the assistant will use the bipolar to coagulate as you expose. There are a lot of little veins out lateral to the hypoglossal. But the idea is we want to come up along this side of the internal carotid to make sure you have distal exposure on the internal. If you don't, you end up running out of room. You're not to the top of the plaque. And I think that's where people get into real trouble. But you can see even with a high bifurcation, if you take the time and effort, you can do it. Actually, one nice thing about the regional block is because they don't have a tube in their mouth, their jaw is not depressed, so the mandible is not as much in the way as it would be with a general endotracheal unless you did a nasotracheal intubation. So, in a common external, here's superior thyroid. Again, take a lot of time to come up along the internal. Another thing that really helps that some people don't do is to dissect behind the carotid. If you stay right on the carotid artery, that's perfectly safe. If you get deep, you can hit the superior laryngeal nerve. And so you have to make sure you're right on the carotid. But if you do that, circumferential dissection really lets you free up the vessel, and you can both elevate it out of the wound and pull it proximally. So you can get very high on the internal carotid. I mean, we routinely can get up to C1. So it does help. So as I said, this was a high bifurcation. But you can see we've got a lot of internal carotid exposed now. Now we're going to put a vascular tape around the external. And you'll notice we try not to, you can manipulate the vessel, but you don't squeeze it. You don't want to do anything that's going to release the plaque. So here's the proximal part of the external. A vascular tape goes on there, and we put a snap on that. Then we put a vascular tape around the internal, but just leave it open. It's just a handle. The vascular tape on the common goes around twice. And then we can use that to put a Rommel tourniquet that will hold a shunt in if we need to place a shunt. And I don't use any extra clamps or anything for the shunt, so those aren't in the way. We use a shunt, the short one, if need be. Okay, so here's that Rommel tourniquet. All right, so now we've got our retractors in place. This is just a little patty I'll sometimes stick under the carotid if we've done a circumferential dissection. It helps stabilize it a little bit and brings it up out of the wound. This is an aneurysm clip, temporary aneurysm clip, and that one's going on the superior thyroid. You notice it's placed so it lies flat and doesn't catch your suture. So now the next clip is going to go on the internal, and you want to get it as far up as you possibly can. So get it on where you can see it well, open it, slide it up as far as you can. Then we use a vascular clamp on the common carotid. It's an angled DeBakey. And another aneurysm clip on the external. So with the patient fully awake, you make sure they can squeeze their hand, talk to you, get 5,000 of heparin before cross-clamping. And then we make a small incision, usually just at the junction of the common and internal, and use an angled pot scissors to extend the incision proximal and distal. This is a Woodson-Adson dissector. It's got a very nice little dissecting arm on it that you can use to develop this plane between the plaque and the normal vessel. And you'll almost always see a place where the plaque starts to separate. If you don't, you have to develop that plane. I'll usually go distal and try and get it to feather out. You'll notice the distal end actually just feathers out. Proximally, the plaque will extend to the aortic valve, so you can't get the whole thing out. So you get past the thick part of the plaque and then just transect it. So now this is free in the common, in the internal, and you can just pull the plaque out of the external. But this is what you want to see. You want to see a nice, smooth surface. You want to see no residual plaque. Occasionally, but very rarely, we'll put a tacking suture in because you really should strive to get above the plaque and have it feather out. Once you're completely convinced that all of the plaque is gone, start a closure, and you always start the closure distally. The reason for that is if you end up with a little bit of a dog ear in the common carotid, that's not a big deal. If you ended up with a little bit of a dog ear at the internal carotid, that's really hard to repair in a satisfactory fashion. I use a 5.0 pro-lean. You can use 6.0. I don't think it matters. I rarely patch graft. Here, we're back bleeding the vessel just to make sure there's good back flow before you completely close. If there's not, you open it up. So the vessel's closed now, and you irrigate. It has to be absolute hemostasis. I usually put a little flow seal both in that place behind the carotid where we dissected and along the incision. And again, irrigate, irrigate, make sure there's absolutely no bleeding. And then we close with a couple of vicryl sutures in the platysma just to line things up nicely, and then some 4.0 subcuticular vicryls to pull the skin edges together, and dermabond on the skin. And this incision, I mean, will disappear in about six weeks or so. I mean, it's really a very nice cosmetic result. And it's surprising how much people care about that. So the patient's completely awake. Clean things off. We'll put a little dermabond on there. And that will be an almost invisible scar. Here's the plaque. You can see this. I think the reason that endarterectomy remains the treatment of choice is almost all of the symptoms from these plaques are from distal emboli. And it's hard for me to understand how traversing that plaque with any type of catheter cannot, in a high percentage of cases, cause some distal embolization. And I think the data are pretty good to support that. So that's a brief video. Again, I'm sorry that it's not the kind of quality you get when you do something under the scope. But I think we should take the rest of the time to answer any questions. If you need to go back to something on the video, I'd be happy to try and find it for you. So why don't we make this a question and answer at this point. Howard? I'll start. First of all, Bob, that was excellent. And just for the residents, just so you appreciate, so this is the second year that we've been able and fortunate to have the president of the AANS come. And I think it's really important for you to take advantage of that opportunity. So if there are questions and things that you have on your mind while he's here, you should talk to him a little bit about neurosurgery and yourselves. I think it would be really useful. Yeah, that would be great. Love to do it. The other thing is that, as you know, I do both EMBO and open surgery. But the fastest-growing part of my practice now is open and darterectomy. We've hired a bunch of stroke neurologists at our place. They're exclusively sending their carotids to us. So you really need to know this operation, and you really need to know this operation well. And the question I have for Bob is, as a guy that wasn't doing a lot of endarterectomies and now I am, is what do you do when you get in there and you see one of these large lymph nodes that's sort of usually right on the bifurcation? Do you resect them? Do you try to move them out of the way? Yeah, I almost always, if they're really huge, I'll take them out. And one of the things I've learned through trial and error, if you go medial to the node, you can do it almost bloodlessly. You just go around and bipolar medially and then peel it out. If you try and go the other direction, it's a bloody mess. Now, if you have, you know, sometimes you'll see a whole bunch of these little nodes along the jugular chain. And in those, again, I just dissect medial. I don't take them out, but they can retract with the jugular vein. So, but I know exactly what you mean. The real big ones are just always in your way, and you've got to get rid of them. Hey, Dr. Harville. I think there's someone in the back here. Yeah, sorry, question. So, here in Memphis, we do all of our carotids asleep. How often do you have sort of acrobatics on the OR table with an awake patient? And with an open neck, if someone's reaching up or just can't tolerate it, what do you do? Yeah, well, I can tell you, I just reviewed our last, I've done over 2,000 endarterectomies now. The last 500 I just reviewed for a talk I gave. Of the last 500, we did three asleep. Those three, one was a person who was deaf, so I couldn't talk to the person. The other was a person who spoke only Spanish, and my Spanish is completely inadequate to converse with the patient. And then there was one person who just absolutely refused, said he will not have this done awake. So, I think with coaching ahead of time, almost everybody can get through this. I think one of the keys is to have the person really awake. I think the idea is, well, we're doing this awake, so we better really sedate the person. And as soon as you sedate someone, they're confused. They don't know what's going on. It's hard to talk to them. And so, that's when I think you get the agitated patient. So, I tell my anesthesiologists, they can get out a bottle of whatever Valium-like compound they want. They can wave it over the person's head, but I don't want them actually injecting any into them. And that really helps. Occasionally, you'll have someone who gets kind of agitated during the case. The most common thing I've seen is someone who has to void. We don't put a Foley in, and people are very, very reluctant to just empty their bladder in front of other people. So, we'll have a nurse put some type of receptacle there and try and convince them to just let it go. And when that happens, their agitation gets better. If you had someone who really, really just went bonkers on the table, I've talked to my anesthesiologists in the past, and they're usually prepared. They have some propofol, oral obturator airway, that kind of stuff that you could do in a real emergency. But I must say, it's one of those things you worry about, but it just doesn't happen with any degree of frequency. Two other quick points. One, you have to do an expeditious operation. People are fine lying on a table for an hour, an hour and a half, but if this is going to be a marathon, it's not a good idea. We've actually tracked all the parameters of this. For the cases that I do, the whole thing myself, the mean time is a little under an hour. So you can move through this operation very expeditiously without hurrying. If the residents do half of the procedure, either the endarterectomy or the dissection, it goes up to about an hour and 15 minutes. If the residents do the whole procedure, it goes up to about an hour and a half, which is still very tolerable. But I think not dawdling, really moving through the case is important. And I think the atmosphere in the room means a lot. If the surgeon is nervous, if the scrub nurse is nervous, if it seems like this is something really way out there to do it away and everybody's kind of keyed up, then the patient's going to be nervous. So we do everything we can to keep the patient talking through the case, kind of distract them. I'll tell them that at the end of the case, if you're there talking about the football game last weekend or the kids, that doesn't mean we're not paying attention to you. That means things are going fine. Feel free to join in. So lots of things like that you can do to prevent the agitation. Do you use EEG monitoring as well, and how do you determine which patients you're going to shunt? Well, actually, I think when I was trained to do this with general anesthesia and EEG, and the first part of my practice, I did it that way. And when I used EEG, we would put a shunt, usually when the amplitude ipsilateral to the carotid dropped by 50% or more. And we ended up shunting about somewhere around 15% of the carotids with EEG. Since switching over to regional, I mean, I think you have the best monitor, which is a neurological exam in an awake patient. And so our incidence of shunting has actually dropped to a little under 5% with that. Interestingly, even in patients with contralateral occlusion, the incidence of shunting is under 20%. It's about 16%, 17%. So most patients tolerate the cross clamping without developing a deficit for the time that you need to do this operation. Now, if I cross clamp someone and they do develop a deficit, it's my practice to go ahead and take the plaque out first. That usually takes a few minutes, but not very long. And then put a shunt in. And the shunt I use is the sunt straight shunt. It's got sort of an acorn-shaped piece on the common carotid side, which is larger, another acorn-shaped piece on the internal carotid side, which has a smaller diameter. It's reinforced with wire so it won't crimp. And the procedure to do that is you, if you remember the setup, you have your Rommel tourniquet and a clamp on the common, and then you have your aneurysm clip on the internal. So I'll slide the common carotid end of the sunt shunt into the common carotid and cinch down on the Rommel clamp, make sure that's in place and isn't going to move. Then you flush it quickly by opening your vascular clamp and close it again. Now you take the internal side and just slide it up the internal carotid and have your assistant take the aneurysm clip off, and that little acorn piece prevents back bleeding. So you slide that shunt in, and then once that's in place, just open the common carotid clamp. Now you've reestablished flow. And usually you can get your plaque out and get the shunt in place within five minutes, and they're going to tolerate that. And then with the shunt in place, you expect to see their neurological examination or EEG return to normal within a few minutes. The reason I do it that way is I find it hard to work around the shunt to get the plaque out, and I just think you get a better overall result if you can get the plaque out first. And five, six minutes of ischemia from a common or an internal carotid in the neck occlusion, basically everyone tolerates. Yes, sir? I guess my question is, in your patients with poor cardiac function, what are your outcomes compared to what's been published with people doing it? Well, we've done a lot of publishing. The last thing that I published was actually in a Chinese journal because I needed an article for a talk, but it was 1,500 carotids, and it was a multivariable analysis of outcomes. And we looked at outcomes in two ways. One was in stroke morbidity, and then the other was in any non-stroke morbidity or death. It turned out that the things that made a difference in the non-stroke morbidity and death, so congestive failure, MI, pneumonia, those sorts of things, using a regional anesthetic was significantly associated with lower complication rates. If you looked at stroke or death, the choice of anesthetic made no difference at all, and that seemed to be about the same in both cohorts. In this last 500 cases, so these were done with aspirin and Plavix pre-op and for six weeks post-op, basically all done with regional anesthesia. The stroke rate was 0.6%. The MI rate was 0.6%. There was one death in that group. I mean, I think that's as good as any data out there. Yeah, I mean, when I was doing redo carotids, I would always patch graph those. I don't do redo carotids anymore because I think those should always go for endovascular treatment. So my number of patch graphs has dropped way down. In the overall series, it's about 8% or 9%, but if you look in this last 500, it's down to about 2% or 3%, and it's basically just someone who has a real, real narrow vessel that you're worried about, you know, the distal diameter, and that's awfully uncommon. If I do use the patch graph, you know, I'll put a couple of double-arm suture in at the top and then just run it down each side. It takes a little longer, but I think the patch graph helps if your end point is making sure there's no residual stenosis on duplex at follow-up. You know, you have a little better numbers with the patch graph than without, but if you look at, you know, stroke rates, long-term durability, I haven't seen any data to say the patch graph is superior to doing a primary closure and just doing it real well. Okay, thank you very much. Thank you.

carotid surgery

carotid endarterectomy

neurosurgeons

stroke neurology specialists

surgical technique

awake operation

hemostasis