ABSTRACT
We occasionally encounter atheromatous plaques so extensive and erosive that they create an outpouching type ulceration into the outer layers of the carotid. Depending on surgeon preference, a number of strategies can be called upon to fix this. In this particular case, which is one of my earlier ones, I excised this area of outpouching and did an end-to-end anastomosis of the wall with interrupted 6-0 Prolene sutures. Today, I think instead I would simply excise the wall widely and use the Hemashield patch to reconstruct a widely patent lumen. Without one of these strategies, the residual wall after endarterectomy would have been sufficiently thin that I think the patient would have been at risk for blowout if managed with only simple conventional endarterectomy and primary repair. The surgeon must be prepared to embrace unusual and creative strategies when faced with these types of variants.
