The posterior cervical triangle approach for high carotid artery exposure in carotid endarterectomy

Technical note

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A new approach in carotid endarterectomy (CEA) was developed for high carotid artery lesions. With the authors' use of the posterior cervical triangle approach, 20 patients with a high carotid artery lesion were successfully treated with CEA. Accessory nerve palsy in 1 patient and hoarseness in 4 patients were encountered postoperatively as transient complications. There were no permanent procedure-related complications. Although this method has some risks, it is a useful method in CEA for high carotid artery lesions.

Abbreviations used in this paper: CEA = carotid endarterectomy; ICA = internal carotid artery.

Article Information

Address correspondence to: Tetsuo Sasaki, M.D., Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan. email:

Please include this information when citing this paper: published online December 23, 2011; DOI: 10.3171/2011.11.JNS11563.

© AANS, except where prohibited by US copyright law.



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    A: Schematic drawing of the cervical triangles. The posterior cervical triangle (PCT) is defined by the posterior border of the sternocleidomastoid muscle (SCM), anterior border of the trapezius muscle (TR), and superior border of the clavicle. The PCT is separated into the occipital triangle (OT) and omohyoid triangle (OHT) by the inferior belly of the omohyoid muscle (OH). The accessory nerve (cranial nerve [CN] XI) passes in the PCT. The cervical triangle (CT) is defined by the anterior border of the SCM, inferior border of the posterior belly of the digastric muscle (DG), and posterior border of the superior belly of the OH. B: Schematic drawing of structures of the retromandibular space during exposure of the distal ICA through the cervical triangle. The facial vein has already been divided in this illustration. AC = ansa cervicalis; CCA = common carotid artery; CN XII = hypoglossal nerve; ECA = external carotid artery; IJV = internal jugular vein; OA = occipital artery; PBDG = posterior belly of digastric muscle; PG = parotid gland.

  • View in gallery

    A: Schematic drawing of a conventional approach and the retrojugular approach through the carotid triangle (black arrow) and the posterior cervical triangle approach (white arrow) for CEA on an axial slice of the cervix. CN X = vagus nerve. B: An axial source image from a CT angiogram of a patient who underwent CEA using the posterior cervical triangle approach. The SCM muscle contains a thin section (arrow).

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    Schematic drawings of patient positioning and the skin incision in CEA using the posterior cervical triangle approach. A patient is placed in the supine-lateral position after induction of general anesthesia by transoral intubation. A 5–7-cm linear skin incision is made along the posterior border of the SCM (A). The thin part of the SCM muscle is split longitudinally and retracted toward both sides (B).

  • View in gallery

    Intraoperative photograph obtained during exposure of the right carotid bifurcation using the posterior cervical triangle approach. The carotid bifurcation was located between the second and third vertebral bodies in this case.


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