ABSTRACT
It may be necessary to explore a complete carotid occlusion by virtue of a postoperative thrombosis or encountering a patient who has acute thrombosis of the carotid artery for other reasons and who happens to be in a position to undergo immediate surgery. When this situation arises, I perform the most gentle dissection possible of the carotid artery and cross-clamp only the common and external carotid arteries; the superior thyroid artery is isolated with a Potts tie in the usual fashion. No clamps are placed on the ICA since placement of a clamp in that location might dislodge thrombus and allow it to migrate cephalad. When the arteriotomy is performed, there should be no backbleeding because all sources of potential backbleeding have been controlled. I place gentle suction up the ICA first, but customarily this is ineffective in establishing backbleeding. My next preferred method is to attach a piece of shunt tubing to the end of a blunt needle and establish a vacuum system by connecting this to a syringe. The shunt tubing can be advanced up the ICA, as demonstrated in this illustration, until it encounters the thrombus, after which the syringe plunger can be drawn back to establish a vacuum. As this is withdrawn, it pulls the thrombus down into the operative field and copious backbleeding often follows. This procedure can be repeated several times, progressively pulling out more pieces of thrombus. Failing this, the technique of choice would be the placement of Fogarty catheters, which will be illustrated next.
