Technical considerations for reconstruction of extracranial carotid artery redundancy concurrent with endarterectomy

Anatomic variations of the cervical internal carotid artery (ICA) are present in a significant incidence of the general population. These variations can include redundancy of the ICA, loops, kinks, and coils. When present, these anatomical variances must be addressed at the time of carotid endarterectomy (CEA) and may contribute to technical complexity associated with the operation. Pre-operative anticipation and familiarity with techniques to address these variant anatomies intraoperatively are of benefit to surgeons who perform carotid endarterectomy. Multiple technical approaches have been described to address these ICA configurations with complex CEA including eversion endarterectomy with proximal transposition of the ICA, standard endarterectomy with rotational proximal transposition or shortening to facilitate re-implantation of the ICA, segmental resection of the redundant endarterectomized ICA with backwall reconstruction and anterior wall patch angioplasty, segmental resection of the common carotid artery with primary re-anastomosis, plication of the ICA, anteposition of the ICA using adjacent muscle bellies, and extraluminal methods such as suturing the arterial adventitia to adjacent muscle and the use of fibrin glue and gelatin. We summarize an optimized approach to carotid endarterectomy considering the breadth of anatomical variations and approaches to correction of them, with an emphasis on the importance of individualized surgical planning and the necessity of the contemporary carotid surgeon's familiarity with technical options and intraoperative adaptability.