New approach for operative management of vascular lesions of the infratemporal internal carotid artery

Direct operative management of aneurysms of the internal carotid artery is associated with significant morbidity. Preauricular surgical approaches to this area can result in violation of the inner ear, temporomandibular joint, or mandibular ramus, and cranial nerves V, VII, IX, X, XI, and XII. A new technique for saphenous vein bypass of the infratemporal and petrous internal carotid artery, using a postauricular curvelinear groove drilled in the mastoid cortex, is described. Proximally, the reverse vein graft is anastomosed to either the internal or external carotid artery, whereas the distal anastomosis is to the horizontal petrous internal carotid artery. The latter is accessed through a small pterional craniotomy. The internal carotid artery is then ligated between points of anastomosis, thus isolating the lesion and eliminating dissection in the infratemporal fossa. The posterior location of the vein graft also avoids potentially infected areas adjacent to the oropharynx, nasopharynx, and soft tissues of the face. Use of the external carotid artery decreases carotid cross-clamp time and minimizes graft length, and creation of a bony canal protects the graft from subsequent compression and kinking.