· Oblique anterior SCM incision mastoid ® SC joint

· Divide skin, subcutaneous tissue, platysma

— Divide transverse Cx nerves supplying anterior neck

· Mobilise anterior border SCM

— Identify & preserve greater auricular nerve

— Careful of accesory nerve in upper end of incision

· Divide facial vein

· Identify & preserve hypoglossal nerve

— Follw ansa up if not clear

— May need to ligate muscular branches to SCM from ECA small branches to IJV

· Posterior belly digastric & parotid in upper end of incision

· Carotid sheath opened

— X identified

— IJV retracted laterally

· Common, ICA and ECA all dissected circumferentially and looped

— NB internal lies posterior to external

· Systemic heparinisation (100U/Kg)

· Sequential clamping: ICA, common, ECA

— ± ICA stump pressures >60mmHg

· Anterolateral arteriotomy: common – ICA

— ± Insertion of shunt: ICA, back bleed then common ± flush

· Elevation of plaque with Watson-Cheyne or MacDonald’s

— Tacking sutures at distal end if necessary (Kunlin sutures)

· Primary or PTFE patch closure

· Flush arteriotomy

· Removal of clamps: ECA, common, ICA

· Skin closure