Isolation of the common carotid artery
Surgical approach to the common carotid artery (arteria carotis communis) is based on clear anatomical landmarks. The main bony landmark is the carotid tubercle (tuberculum caroticum), located on the transverse process of the sixth cervical vertebra.
The approach is performed by opening the posterior wall of the fascial sheath of the sternocleidomastoid muscle (m. sternocleidomastoideus). Tissue dissection is carried out along a grooved probe together with the common fascial sheath of the entire neurovascular bundle.
Isolation of the vessel itself must be performed extremely carefully, bluntly from the surrounding paravascular adipose tissue. During artery mobilization, the surgeon must take into account the complex syntopy (relationship with neighboring structures):
- Anteriorly: the superior branch of the ansa cervicalis (r. superior ansae cervicalis) and the hypoglossal nerve (n. hypoglossus) are located.
- Posteriorly: the vagus nerve (n. vagus) runs.
- Posteriorly and medially: the sympathetic trunk (truncus sympathicus) lies.
Tactics in major vessel injuries
In trauma to the common carotid artery, preserving blood flow is an absolute priority. The surgeon should strive to apply a full-fledged vascular suture or perform plasty to replace the resulting vessel wall defect.
Ligation (applying a ligature) to the common carotid artery is considered extremely undesirable and is performed exclusively under strict vital indications when other methods of hemostasis are impossible. The main danger of ligation is the disruption of blood supply to the brain. According to statistics from the Great Patriotic War, ligation led to ischemia and subsequent softening of brain tissue in 30% of cases.
Exposure of the external carotid artery
Access to the external carotid artery (arteria carotis externa) is most commonly required for its ligation for prophylactic hemostasis. Indications for this surgery include extensive procedures for parotid gland tumors, tongue neoplasms, and maxillary resection.
Execution Technique:
- The skin incision is made along the anterior edge of the sternocleidomastoid muscle, extending 6–7 cm down from the angle of the mandible.
- The anterior wall of the sternocleidomastoid fascial sheath is opened, after which the muscle itself is bluntly retracted laterally.
- The posterior wall of the sheath is incised together with the neurovascular bundle sheath.
The common facial vein and hypoglossal nerve are found on the anterior wall of the exposed area. The main anatomical sign allowing reliable identification of the external carotid artery and distinguishing it from the internal carotid is the origin of branches. The first branches arising from it are:
- a. thyroidea superior (superior thyroid artery);
- a. lingualis (lingual artery);
- a. facialis (facial artery).
During isolation, the vessel must be carefully separated from the superior branch of the ansa cervicalis, as well as from the posteriorly located vagus nerve and internal jugular vein (which lies posteriorly and laterally). The common facial vein draining into the internal jugular vein may block access to the artery; in such cases, it is transected between two ligatures.
Glomectomy (carotid body excision)
Glomectomy is the excision of the carotid body (glomus caroticum). This surgery is indicated for patients suffering from severe bronchial asthma refractory to standard conservative treatment.
To access the glomus, a collar incision is used within the right carotid triangle, strictly at the level of the upper edge of the thyroid cartilage. The surgeon opens the fascial sheath directly above the bifurcation zone of the common carotid artery. The carotid body itself is found on the posterior wall of this bifurcation. The vessels nourishing the glomus and running to it from the bifurcation area are ligated, after which the body is excised with scissors.
As an adjunct to the main procedure, some surgeons perform desympathetization. This consists of the circular removal of the outer layer (adventitia) for about 1 centimeter from the common, external, and internal carotid arteries.
Briefly: answers to topical questions
Which fascial layers of the neck according to Shevukネンko must be sequentially dissected to expose the common carotid artery?
To expose the common carotid artery, it is necessary to sequentially dissect the first, second, and fourth fascial layers of the neck.
- Superficial fascia (1st).
- Investing fascia of the neck (2nd).
- Endocervical fascia (fascia endocervicalis, 4th) — its parietal layer (lamina parietalis fasciae endocervicalis), which forms the common sheath of the neurovascular bundle, is dissected.
Through which vascular anastomoses is cerebral blood flow compensated during common carotid artery ligation?
Cerebral blood flow during common carotid artery occlusion is compensated via extracranial anastomoses and the cerebral arterial circle.
- Occipital artery (a. occipitalis) — through it, blood enters the carotid system from muscular branches of the vertebral artery. Blood flows retrogradely down the external carotid artery to the bifurcation and ascends into the internal carotid artery.
- Circle of Willis (circulus arteriosus cerebri Willisii) — an intracranial anastomosis providing compensation via arteries of the opposite side.
What are the anatomical boundaries of the carotid triangle of the neck where access to the bifurcation is performed?
The anatomical boundaries of the carotid triangle (trigonum caroticum), where access to the common carotid artery bifurcation is performed, are formed by three neck muscles.
- Superiorly — posterior belly of the digastric muscle (m. digastricus).
- Laterally — sternocleidomastoid muscle (m. sternocleidomastoideus).
- Inferiorly — superior belly of the omohyoid muscle (m. omohyoideus).
Which nerves form the ansa cervicalis, the superior branch of which lies adjacent to the carotid artery?
The ansa cervicalis is formed by the union of two roots:
- Superior root (radix superior) — descending branch of the hypoglossal nerve (n. hypoglossus, XII cranial nerve), with the participation of C1 fibers.
- Inferior root (radix inferior) — branches of the cervical plexus.
To memorize the initial branches of the external carotid artery, use the mnemonic: Superior thyroid, Lingual, Facial arteries.
Class and exam questions
What is the main sign that distinguishes the external carotid artery from the internal carotid artery?
The main distinguishing feature of the external carotid artery is the presence of branches arising directly in the neck region, whereas the internal carotid artery gives off no branches in the neck.
Which vein can impede access to the external carotid artery?
Access may be blocked by the common facial vein draining into the internal jugular vein. For convenience of artery isolation, this vein is transected between two ligatures.
In which disease is glomectomy indicated?
Carotid body removal (glomectomy) is performed for severe bronchial asthma that does not respond to conservative therapy.
What else to study on this topic
- Topography and boundaries of the carotid triangle of the neck
- Structure of the neck fascial sheaths according to Shevkunenko
- Syntopy of the internal jugular vein within the bundle
- Technique of Carrel vascular suture placement
- Anatomy of the cervical sympathetic trunk
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