External ventricular drain as a nontraumatic suction device in carotid endarterectomy.

Carotid endarterectomy is a commonly performed operation to remove plaque at the region of the carotid bifurcation. We present our technique to keep the field clear and to minimize potential trauma to the carotid using a neurosurgical external ventricular drain passed behind the common carotid and placed in the dependent position under the arteriotomy.

Carotid endarterectomy is a commonly performed operation to remove plaque at the region of the carotid bifurcation.1, 2 A skin incision is made anterior to the sternocleidomastoid, the platysma is divided, and the sternocleidomastoid is retracted laterally. The facial vein is usually ligated. The common carotid is mobilized, and once the hypoglossal has been identified above the carotid bifurcation, the bifurcation and the internal and external carotids are mobilized.3, 4 To minimize the use of a sucker by the assistant, freeing an extra hand to assist and avoiding potential damage to the surrounding structures, we have found it useful to place an external ventricular drain (EVD) through the fascia surrounding the common carotid immediately adjacent to the artery, proximal to the point where it has been mobilized, paying particular attention to not injure the vagus nerve, which commonly but not always runs in the posterior part of the sheath (Fig 1). The proximal end is then passed under the retractors and out to a suction tube (we use a regulated sucker tube; Fig 2). An EVD is ideal for this purpose as it is constructed of soft Silastic material, has no sharp edges to injure tissue, and provides relatively constant suction along the last 3 to 4 cm of its length (depending on manufacturer), even when one or more of the holes are blocked. This allows the surgeon a relatively unobstructed field of view, and the assistant is not obliged to regularly clear the field of blood. The tip of the EVD can be directed into the arteriotomy with forceps and provides gentle suction with no macroscopic damage to the intima. We use low-flow heparinized saline irrigation to clear the field when suturing the arteriotomy, and having a dependent drain is of great assistance. It also avoids entanglement with the suture in closing the arteriotomy and expedites the operation. The EVD is removed at the conclusion of the case, a layer of Surgicel is placed over the sutured arteriotomy, and the wound is closed as usual with a Jackson-Pratt style drain left in situ over the carotid bifurcation. We have performed this on 20 successive patients without injury or ill effect.

Fig 1

External ventricular drain (EVD) introduced posterior to retractors and left common carotid artery.

Fig 2

External ventricular drain (EVD) connected to regulated suction device.