title: Surgical exposure and resection of the vertical portion of the petrous internal carotid artery: anatomic study.
abstract: OBJECTIVE
  The goals were to determine which surgical approaches, i.e., the preauricular subtemporal infratemporal fossa (PSI), postauricular transtemporal (PAT), and/or subtemporal middle fossa (SMF) approaches, provide optimal exposure of the anterior, posterior, medial, and lateral aspects of the vertical segment of the petrous internal carotid artery (VPCA) and to determine the length of the VPCA that can be resected before a vein graft is necessary.
  
  
  METHODS
  Using 22 cadaveric specimens, we compared the length of exposure of the VPCA provided by the PSI, PAT, and SMF approaches. The segment of the VPCA that was exposed with each approach was measured in millimeters and expressed as a percentage of the total length of the VPCA. Resection of the VPCA in 1-mm increments was performed until a graft would be necessary; the total length of the resected segment was recorded in millimeters and was also expressed as a percentage of the total length of the VPCA.
  
  
  RESULTS
  The PSI approach provided average exposures of 14.1 mm (95% of the total exposure possible) of the anterior aspect and 14.3 mm (96%) of the lateral aspect of the VPCA; resection of less than 2.3 mm (16%) of the VPCA could be repaired with an end-to-end anastomosis. The PAT approach provided average exposures of 10.5 mm (71 %) of the lateral aspect and 10.0 mm (76%) of the posterior aspect of the VPCA; resection of less than 2.8 mm of the VPCA could be repaired with an end-to-end anastomosis. The SMF approach provided average exposures of 6.1 mm (45%) of the anterior aspect and 5.4 mm (41 %) of the lateral aspect of the VPCA; resection of less than 2.4 mm (24%) of the VPCA could be repaired with an end-to-end anastomosis.
  
  
  CONCLUSIONS
  Lesions on the anterior and lateral aspects of the VPCA can be fully exposed with the PSI approach or partially exposed with the less invasive SMF approach. Lesions on the posterior aspect of the artery are best exposed with the PAT approach. Lesions on the medial aspect of the VPCA cannot be exposed unless the VPCA is mobilized in the PSI approach. Resection of less than approximately 2.5 mm (20%) can be repaired with an end-to-end anastomosis, regardless of the approach used.
authors.affiliation: Division of Neurosurgery, St. Michael's Hospital, Toronto, Ontario, Canada.
authors.forename: A S
authors.initials: AS
authors.lastname: Suhardja
authors.forename: M D
authors.initials: MD
authors.lastname: Cusimano
authors.forename: A M
authors.initials: AM
authors.lastname: Agur
mesh_terms: D002343:Carotid Artery, Internal / Q000502:physiology* / Q000601:surgery*; D006801:Humans; D019635:Neurosurgical Procedures / Q000379:methods*; D010579:Petrous Bone / Q000098:blood supply* / Q000601:surgery*