ABSTRACT
In the majority of CEA procedures, the plaque can be removed from the ECA without having to open that vessel as a separate incision. Once the plaque is freed from the common and internal carotid arteries, the remaining plaque wall is grasped with vascular forceps to pull down the plaque from the ECA orifice. This basically inverts the ECA lumen as the plaque is pulled back and usually results in a clean distal break-off up in the region of the occluding bulldog clamp. If the plaque does not immediately release, the bulldog clamp can be temporarily opened, allowing the plaque to be popped down from the distal ECA. It is also helpful to sweep around the interface between the plaque and ECA residual vessel wall with either a Penfield No. 4 dissector or a curved mosquito clamp, thereby freeing up some of these atherosclerotic fragments. It is necessary to open the ECA separately only if the plaque does not come out easily in this fashion.
