ABSTRACT
When the arteriotomy is complete and the decision has been made whether or not to shunt, plaque removal begins. I start at the lateral edge of the vessel using a Penfield No. 4 microdissector or a Freer dissector and rub gently back and forth along the vessel wall. In a primary case, it usually falls into a cleavage plane just outside the atheromatous intimal plaque, which is easily dissected. Gentle dissection is required to avoid buttonholing the residual vessel wall, which may be quite thin. I prefer the Penfield microdissector, which is always turned medially so that no sharp edge extends through the plaque into the vessel wall. The dissection continues in a circumferential fashion approximately halfway around the vessel, and the same process is repeated on the medial side. Dissection also proceeds in a rostral-caudal direction in an attempt to gently free up both the ICA attachments of the plaque and the CCA, which is prepared for sharp transection.
