Surgical access to the distal cervical segment of the internal carotid artery and to a high carotid bifurcation – integrative literature review and protocol proposal

Conte Neto, Nicolau; Gonçalves, Thais Tapajós; Louis, Clarina; Ikikame, Jonas; Góes Junior, Adenauer Marinho de Oliveira

doi:10.1590/1677-5449.202101932

Nicolau Conte Neto

Centro Universitário do Estado do Pará – CESUPA, Belém, PA, Brasil.

http://orcid.org/0000-0001-5152-1277

Thais Tapajós Gonçalves

Universidade Federal do Pará – UFPA, Belém, PA, Brasil.

Clarina Louis

Universidade Federal do Pará – UFPA, Belém, PA, Brasil.

Jonas Ikikame

Universidade Federal do Pará – UFPA, Belém, PA, Brasil.

Adenauer Marinho de Oliveira Góes Junior

Centro Universitário do Estado do Pará – CESUPA, Belém, PA, Brasil.

http://orcid.org/0000-0001-9345-9539

Conflicts of interest: No conflicts of interest declared concerning the publication of this article.

Correspondence Adenauer Marinho de Oliveira Góes Junior Rua Domingos Marreiros, 307/802 CEP 66055-210 - Belém (PA), Brasil Tel.: +55 (91) 98127-9656 E-mail: adenauerjunior@gmail.com

Author information NCN - Postdoctoral fellow in Odontologia, Universidade Federal de Minas Gerais (UFMG). TTG - Board certified in Cirurgia do Aparelho Digestivo, Universidade Federal do Pará (UFPA). CL - Dental surgeon, Universidade Federal do Pará (UFPA). JI - Oral and maxillofacial surgeon, Universidade Federal do Pará (UFPA). AMOGJ - Postdoctoral fellow in Ciência Cirúrgica Interdisciplinar, Universidade Federal de São Paulo (UNIFESP); Full member and coordinator at Departamento Científico de Trauma, Sociedade Brasileira de Angiologia e de Cirurgia Vascular (SBACV).

Author contributions Conception and design: AMOGJ, NCN Analysis and interpretation: AMOGJ, NCN, TTG Data collection: CL, JI, TTG Writing the article: AMOGJ, NCN, TTG Critical revision of the article: AMOGJ, NCN Final approval of the article*: NCN, TTG, CL, JI, AMOGJ Statistical analysis: AMOGJ Overall responsibility: AMOGJ *All authors have read and approved of the final version of the article submitted to J Vasc Bras.

Structure	Anatomic landmarks	Repercussions of injury
Nerve V₃ (trigeminal/ mandibular ramus)	Emerges from the skull through the foramen ovale. Its downward path accompanies the inferior alveolar artery, medial to the mandibular ramus. It continues deep to the lateral pterygoid muscle and then between the sphenomandibular ligament and the ramus of the mandible to the mandibular foramen.	Paresthesia of the teeth of the mandible, the region of the mentum, and the lower lip.
Nerve VII (facial)	Emerges from the base of the skull at the stylomastoid foramen. It runs at the same depth or slightly deeper than the superior margin of the digastric muscle posterior belly. It is accompanied by the stylomastoid artery. It has a relationship with the tympanomastoid fissure, which is from 7 to 15 mm lateral to the exit of the VII cranial nerve at the stylomastoid foramen.	Facial paralysis.
Nerve IX (glossopharyngeal)	It emerges from the skull at the jugular foramen. It runs medial of the styloid process and lateral of the stylopharyngeus muscle and the internal carotid artery. It continues caudally posterior to the stylopharyngeus muscle. Anteriorly, it is located between the pharyngeal constrictor muscles (superior and middle).	Loss of sensitivity in the posterior third of the tongue; reduced parotid gland secretion; Vernet syndrome; Collet Sicard syndrome.
Nerve X (vagus)	Emerges from the skull at the jugular foramen. The superior portion runs posterior and medial to the internal carotid artery. The inferior portion runs between the common carotid and internal jugular arteries. Internal branch of superior laryngeal nerve: descends to the thyrohyoid membrane, base of the tongue, epiglottic region, and mucous membrane of the larynx. External branch of superior laryngeal nerve: runs alongside the inferior pharyngeal constrictor to the cricothyroid muscle.	Paralysis of vocal cords and dysphagia (paralysis of soft palate levator muscle and pharyngeal constrictor muscles); Vernet syndrome; Collet Sicard syndrome.
Nerve XI (accessory)	Emerges from the skull at the jugular foramen. Runs between the insertion of the digastric muscle posterior belly into the mastoid process and the sternocleidomastoid muscle.	Scapular winging and shoulder droop (paralysis of the trapezius and sternocleidomastoid muscles); Vernet syndrome; Collet Sicard syndrome.
Nerve XII (hypoglossal)	Emerges from the skull at the hypoglossal foramen, running along the inferior margin of the digastric muscle posterior belly.	Unilateral paralysis and atrophy of the tongue.
Common carotid artery	Right: branch of the brachiocephalic trunk. Left: branch of the aortic arch. Runs superior and posterior to the sternoclavicular joint. Normally bifurcates at the height of the superior margin of the thyroid cartilage (C3/C4).	-
External carotid artery	Runs in an anterosuperior direction, posterior to the mandible and deep to the digastric muscle posterior belly and stylohyoid muscle.	-
Internal carotid artery	Runs cranially within the carotid sheath. Anterior of the transverse processes of the superior cervical vertebrae.	-
Internal jugular vein	Located posterior of the internal carotid artery and the glossopharyngeal, vagus, and accessory nerves until it enters the carotid sheath. Located internal of the sternocleidomastoid muscle.	-
External jugular vein	Formed in the interior of the parotid gland. Follows a descending path deep to the platysma muscle and superficial to the sternocleidomastoid.	-

Advantages	Disadvantages	Complications	Time
Low morbidity. Easy to perform. Expands the surgical field (from triangular to rectangular). Unaffected by variables such as sex, age, and length of neck.	Need for nasotracheal intubation or submental conversion of intubation. Anatomic distortion of the surgical field, with a theoretical increase in risk of hypoglossal nerve injury. Enlargement of the surgical field is limited in patients with a very steep articular eminence and a deep articular fossa.	Risk of pathological luxation of the mandible; temporomandibular dysfunction.	10-15 min

Advantages	Disadvantages	Complications	Time
Permits exposure of the portion of the internal carotid artery covered by the styloid apparatus. The decision to perform this maneuver can be made intraoperatively. Can be combined with temporary mandibular subluxation to increase exposure.	Potential risk of injury to IX cranial nerve and the pharyngeal branches of the vagus nerve.	Dysphagia	-

Osteotomy	Advantages	Disadvantages	Complications	Time
Ramus	Access can be obtained via the same incision made to expose the carotid. Exposure and sectioning are planned to avoid injuries to the facial and mandibular nerves.	Increased operating time.	Postoperative infection and malocclusion.	-
Subcondylar	Preserves the inferior and lingual alveolar nerves. Avoids toothed areas of the mandible.	Increased operating time.	Postoperative infection and malocclusion.	-
Anterolateral	Larger access.	Increased operating time.	Postoperative infection and malocclusion; more visible scarring of chin and lip; prior extraction of the tooth related to the osteotomy line; high risk of damage to inferior alveolar nerve.	-

[1] Conflicts of interest: No conflicts of interest declared concerning the publication of this article.

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Surgical access to the distal cervical segment of the internal carotid artery and to a high carotid bifurcation – integrative literature review and protocol proposal

Abstract