ABSTRACT
A rigid protocol must be followed for the reconstitution of flow in the clamped carotid tree. When the suture line is completed in the ICA, a second suture line comes up the CCA. These suture lines meet in the region of the carotid bulb and are eventually tied together. First, however, all three vessels are backbled, usually in the sequence of internal, external, and common carotid arteries. I hold a finger over the suture line to prevent blood from spraying the surgeon’s or assistant’s face when the CCA is briefly opened. With a little practice, no more than 1 or 2 mL should escape during this process. When the vessels have been backbled and it is clear that no thrombosis of a distal vessel has occurred or inadvertent stenosis has been created by the suture line, the vessels are ready for final closure. On rare occasions, ICA backbleeding will be inadequate; this is most often a consequence of having a 0 silk string pulled taut by a mosquito clamp, holding the vessel closed even when the bulldog clamp has been released. With gentle relaxation of this occluding silk, backbleeding usually ensues. In a case of true backbleeding failure, it may be necessary to advance an exploratory shunt tube up the ICA, drawing back with suction to reestablish flow, just as in the case of complete thrombosis of the carotid tree. This technique is illustrated in Fig. 4-2. Failing this, a Fogarty catheter also may be used to reestablish flow. Fortunately, this is an extremely rare occurrence.
