Extra-Intimal Carotid Endarterectomy: Two-Dimensional Microsurgical Approach.

Carotid endarterectomy is a standard treatment for patients with symptomatic carotid artery stenosis. Surgical techniques require a full-thickness incision (longitudinal, diagonal, or transverse) through the carotid wall. This incision results in significant plaque disruption and precludes harvesting of intact specimens for research. The video demonstrates an endarterectomy technique for removal of intact plaques using an extra-intimal approach. A 70-year-old man presented to our service with a history of aphasia. Neuroimaging showed the presence of an 80%-90% calcified stenosis of the left internal carotid artery. Brain magnetic resonance imaging revealed multiple acute and subacute left hemispheric strokes. The decision was made to proceed with extra-intimal carotid endarterectomy of the left internal carotid artery after obtaining informed consent. To this end, after appropriate exposure of the carotid artery bifurcation, the adventitia and the tunica media were transected longitudinally followed by the creation of a circumferential dissection plane between the tunica media and the intima (i.e., extra-intimal). After sharply transecting the intimal inlets and outlet of the atheroma, the arteriotomy was repaired in usual fashion (Video 1). The patient was discharged home the next day without complications and remained asymptomatic at 1-year follow-up. To date, this technique has been successfully used in 55 consecutive patients with no intraoperative or postoperative complications. This technique is fast, reproducible, and effective even in highly calcified lesions that are otherwise hard to cut. The approach requires minimal arterial wall and atheroma manipulation and procures intact specimens for high-quality research.