Mandibular Subluxation for Distal Cervical Exposure of the Internal Carotid Artery (original) (raw)

Mandibular subluxation for distal internal carotid exposure: Technical considerations

Journal of Vascular Surgery, 1999

Purpose: Carotid endarterectomy (CEA) has become one of the most commonly performed vascular procedures, because of the beneficial outcome it has when compared with medical therapy alone and because of the anatomic accessibility of the artery. In cases of distal carotid occlusive disease, high cervical carotid bifurcation, and some reoperative cases, access to the distal internal carotid artery may limit surgical exposure and increase the incidence of cranial nerve palsies. Mandibular subluxation (MS) is recommended to provide additional space in a critically small operative field. We report our experience to determine and illustrate a preferred method of MS. Methods: Techniques for MS were selected based on the presence or absence of adequate dental stability and periodontal disease. All patients received general anesthesia with nasotracheal intubation before subluxation. Illustrations are provided to emphasize technical considerations in performing MS in 10 patients (nine men and one woman) who required MS as an adjunct to CEA (less than 1% of primary CEAs). Patients were symptomatic (n = 7) or asymptomatic (n = 3) and had high-grade stenoses demonstrated by means of preoperative arteriography. Results: Subluxation was performed and stabilization was maintained by means of: Ivy loop/circumdental wiring of mandibular and maxillary bicuspids/cuspids (n = 7); Steinmann pins with wiring (n = 1); mandibular/maxillary arch bar wiring (n = 1); and superior circumdental to circummandibular wires (n = 1). MS was not associated with mandibular dislocation in any patient. No postoperative cranial nerve palsies were observed. Three patients experienced transient temporomandibular joint discomfort, which improved spontaneously within 2 weeks. Conclusion: Surgical exposure of the distal internal carotid artery is enhanced with MS and nasotracheal intubation. We recommend Ivy loop/circumdental wiring as the preferred method for MS. Alternative methods are used when poor dental health is observed. (J Vasc Surg 1999;30:1116-20.)

Mandibular subluxation for high carotid exposure

Journal of Vascular Surgery, 1984

Twenty-four patients with internal carotid artery lesions extending above the second cervical vertebra underwent mandibular subluxation for additional exposure. The original technique of bilateral arch bar wiring requiring 90 minutes for application has evolved into a circummandibular/transnasal wiring technique requiring approximately 10 minutes. Subluxation of the mandibular condyle 10 to 15 mm anteriorly results in displacement of the mandibular ramus 20 to 30 mm anteriorly. This technique provides a marked increase in exposure of the internal carotid artery up to the base of the skull by transforming a triangular operating field into a rectangular field. The technique is quick, easy to perform, and not associated with objective or subjective temporomandibular joint dysfunction. (J VASC SURG 1984; 1:727-733.)

Skull Base Approach to Carotid Artery Lesions: Technique, Indications, and Outcomes

Skull Base, 2011

Operative exposure of the high parapharyngeal and intrapetrous segments of the carotid artery presents a challenge to the skull base surgeon. Endovascular approaches have enhanced the accessibility of this area, but some lesions may not be amenable to endovascular management and long-term results are lacking. Open approaches therefore remain an important part of the treatment strategies for lesions in this area.

Double Mandibular Osteotomy for Access to High-Carotid Pathology

Annals of Vascular Surgery, 2021

Background: Anecdotal experience demonstrates the existence of patients with superiorly located carotid stenosis, neoplasms, or aneurysms where the mandible obstructs effective surgical access using standard techniques. As carotid pathology extends anatomically beyond the limits of standard operative technique, additional exposure becomes paramount to safely and effectively address the lesion. Double mandibular osteotomy (DMO) is one of several techniques to obtain additional exposure to high-carotid pathology; however, there is no large series to address the outcomes of patients undergoing this procedure. Methods: A retrospective case series was performed for all patients undergoing surgery for carotid pathology from 2011e2019 that could not be approached with standard cervical incision. The primary predictor variable was higheanatomic carotid pathology necessitating DMO. The primary outcome variable was early and late complications sustained by patients. Results: Fifteen patients met study criteria and underwent 16 DMOs to access high-carotid pathology including carotid stenosis (n ¼ 8 patients), carotid aneurysm (n ¼ 2 patients), and carotid body tumor (n ¼ 8 patients). Two patients had dual ipsilateral pathology with one patient having both carotid artery stenosis and aneurysm, and the other patient diagnosed with carotid artery stenosis and carotid body tumor. One patient had bilateral carotid artery stenosis, each requiring high anatomic exposure for treatment. Early complications occurred in 8 patients. Five patients experienced significant dysphagia requiring enteral feeding, and 2 patients developed malocclusion directly related to the double mandibular osteotomy. One patient experienced contralateral cortical watershed infarcts. Late complications included one patient developing osteomyelitis of the mandible, and this patient also developed distal mandibular segment screw exposure. The comparison of the outcome groups for categorical predictor variables using Fisher's exact test detected no statistically significant differences for gender, hypertension, hyperlipidemia, type 2 diabetes, chronic obstructive pulmonary disease, tobacco use, chronic kidney disease, or cerebrovascular disease. For the continuous variable comparisons, independent-samples t-tests detected no difference between the complication groups for age, operative time, or years of follow-up. No significant differences were found between the groups for body mass index or intraoperative blood loss. Conclusions: The double mandibular osteotomy provides excellent exposure and surgical access to the distal internal carotid artery for repair of vascular pathology with acceptable outcomes and long-term complications compared with previously reported techniques. Because of the early complications realized with the DMO, we recommend the procedure for symptomatic patients with a high risk of failing medical therapy alone and not appropriate for endovascular treatment as well as those patients with tumors requiring surgical intervention.

Study of Variations of Cervical Segment of Internal Carotid Artery

Journal of Anatomical Sciences

Introduction: Presence of variations in the course of the cervical (extracranial) part of the internal carotid artery (I.C.A.) in the form of tortuosity, kinking, coiling or looping is a rare condition. These may be attributed to embryological or acquired factors. Patients with such variations may be asymptomatic in some cases, whereas, they may develop cerebrovascular symptoms due to carotid stenosis affecting cerebral circulation. Materials and methods: The present study was performed during routine undergraduate dissection classes in total 21 human cadavers (6 females and 15 males) on bilateral sides. Results: Bilateral kinking and looping of the cervical part of the I.C.A. was found in two cadavers. Conclusions: The risk of transient ischemic attacks (TIA) in patients with carotid stenosis is high and surgical correction is indicated as a part of treatment. Further, patients having these variations are more prone to injury during radical neck dissection and other surgical operat...

Localization of the Carotid Bifurcation According to Hyoid Bone and Mandibular Angle

International Journal of Morphology, 2017

The aim of this study was to determine the carotid bifurcation level in relation with the hyoid bone and mandibular angle. Common carotid artery is the largest artery in the neck, and it gives off two terminal branches, namely external and internal carotid arteries. The bifurcation level of it shows variations, however it is usually situated at the level of C4 vertebra or at the upper border of thyroid cartilage. On the other hand, carotid bifurcation may be situated as low as T3 vertebra, or as high as the level of hyoid bone. In this study, conventional angiographic images of 112 patients were used. The distances of carotid bifurcation to hyoid bone and mandibular angle were measured on those images. In addition, right and left side difference was determined. The distance of carotid bifurcation level to the mandibular angle was measured as 21.26 ± 8.57 mm on the right and 20.25 ± 8.75 mm on the left side in males, and 19.72 ± 8.89 on the right, and 18.5 ± 9.25 mm on the left side in females. Distance between the carotid bifurcation level and hyoid bone ranged 1.94 ± 12.69 mm in female and 3.04 ± 9.00 mm in male on the left side. Having information about the level of carotid bifurcation is important in surgical and radiological procedures for determining the appropriate surgical procedure, and to prevent complications. We believe that the results of this study will shed light to planning of all interventions concerning common carotid artery.

Arteries in the posterior cervical triangle in man

Clinical Anatomy, 2005

Due to frequent changes in the anatomical nomenclature of the arteries in the posterior cervical triangle (lateral cervical region), anatomical and surgical papers relating to these topics are sometimes difficult to understand and are hard to compare. These changes, coupled with improper knowledge of the gross anatomy and nomenclature of the arteries in the posterior cervical triangle, have presented difficulties in musculocutaneous flap planning, especially in plastic and reconstructive surgery. As an illustration of this concern, the term, transverse cervical artery (A. transversa colli [cervicis]), and its associated branches, have been used frequently over the past several decades with different meanings. In an effort to address this nomenclature challenge and to offer a rational basis for arguing specific name changes, a total of 498 neck-halves were investigated in Graz, Innsbruck, and Munich. Lateral neck dissections were carried out to expose the subclavian artery and those branches destined for the posterior cervical triangle, specifically, the superficial cervical artery, the dorsal scapular artery, and the suprascapular artery. The course of these arteries and details of their origins and branching patterns were documented. Several arose either as direct branches or from trunks. The convention used in labeling trunks was similar to that described for other trunk formations in the body (e.g., linguo-facial trunk). Four trunks were observed and named according to the branches that arose from each. A cervico-dorsal trunk gave origin to the superficial cervical and dorsal scapular arteries, and was found in 30% of cases. A cervico-scapular trunk gave rise to the superficial cervical and suprascapular arteries in 22% of cases, and a dorso-scapular trunk provided origins for the dorsal scapular and suprascapular arteries in 4% of cases. A cervico-dorso-scapular trunk gave origin to the superficial cervical artery, the dorsal scapular artery, and the suprascapular artery, and was found in 24% of cases. Each of these trunks, in turn, arose from either the subclavian artery or from the thyrocervical trunk. This labeling convention necessitated omitting the term, transverse cervical artery, because this term has become inherently imprecise and variously used over the years. This study describes a simple, uniform, and rational basis for standardizing the nomenclature of the arteries in the posterior cervical triangle. Clin. Anat. 18:553-557, 2005. V V C 2005 Wiley-Liss, Inc.

Proximity of the maxillary artery to the neck of the mandibular condyle: anatomical study

Oral and Maxillofacial Surgery, 2019

Purpose The objective of this study was to evaluate the anatomical distance of the maxillary artery, the most superior portion of the condyle and subcondyle in standardized coronal sections, acquired from 16 hemifaces in 8 cadavers. Methods Measurements were taken to evaluate the distance between the uppermost portion of the mandibular condyle and the height of the maxillary artery (AB) and between the lateral (CD) and medial (EF) sides of the condylar neck to the artery. Results The mean for AB was 21.1 mm hemiface right and 22.9 mm left on the anterior face, 22.5 mm and 20.7 mm, respectively, on the rear face. The CD measurement presented 6.7 mm right side in the anterior face and 6.3 mm left, and the posterior face was 6.3 mm right side and 5.4 mm left; EF presented a mean of 2.2 mm right and 1.5 mm left on the anterior face and 1.6 mm for both sides on the posterior face. Conclusions There was no statistically significant difference between hemifaces. The proximity of the maxillary artery to the medial face of the neck of the mandibular condyle is millimetric and presents risks of severe hemorrhage for interventions in the infratemporal fossa.