Retrograde carotid fat pad flip method for carotid exposure during carotid endarterectomy.

BACKGROUND: Exposure of the distal internal carotid artery (ICA) during carotid endarterectomy (CEA) can be challenging in anatomically difficult cases. We present the retrograde carotid fat pad (CFP) flip method, a cranial-first, layer-oriented exposure strategy based on preservation of the fibro-fatty layer overlying the carotid sheath. METHODS: The CFP was used as a surgical descriptor for the fibro-fatty tissue overlying the carotid sheath within the carotid triangle. In this method, the cranial CFP boundary is established first along the posterior belly of the digastric muscle, after which the preserved CFP is mobilized and flipped laterally with the carotid sheath. We retrospectively reviewed 61 consecutive patients who underwent CEA using this planned exposure strategy between 2022 and 2024. RESULTS: The cohort included 6 high carotid bifurcations and 2 twisted ICAs. Carotid exposure was completed as planned in all patients, with no conversion. The mean carotid system exposure time was 66.0 ± 13.6 min, the mean operative time was 144.7 ± 25.4 min, and the median estimated blood loss was 5 mL. Great auricular nerve dysfunction occurred in 3 patients, was limited to lower auricular sensory disturbance, and resolved by the 6-month follow-up. No stroke, myocardial infarction, or death occurred within 30 days. CONCLUSION: The retrograde CFP flip method is a feasible cranial-first exposure strategy for CEA. It may help create a shallow, wide, fat-free field toward the distal ICA when early cranial orientation and stable distal ICA exposure are desirable.