The crab technique for complex carotid bifurcation disease involving the proximal external carotid artery: a case report

Carotid endarterectomy (CEA) is an established treatment for carotid artery stenosis. However, complex carotid bifurcation disease involving the proximal external carotid artery (ECA) may increase the technical difficulty of conventional CEA. We describe the Crab technique, a modified CEA approach combining proximal ECA exposure, concomitant endarterectomy, and Y-shaped patch reconstruction. A 68-year-old man with severe right carotid bifurcation stenosis underwent the Crab technique. Preoperative computed tomography angiography showed severe stenosis at the origin of the right internal carotid artery with concomitant proximal ECA involvement. The procedure included extended arteriotomy onto the proximal ECA, direct common, internal, and external carotid endarterectomy, and reconstruction with a surgeon-modified Y-shaped patch. The postoperative course was uneventful, and the patient was discharged without neurologic or wound-related complications. The Crab technique may represent a technically feasible modification of conventional CEA in selected patients with complex carotid bifurcation disease involving the proximal ECA. It allows direct plaque removal and bifurcation-oriented reconstruction while preserving the native anatomy. However, its safety, durability, and appropriate indications require further evaluation in larger case series with longer imaging follow-up.