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Kutovaya AS, Golovyuk AL, Chupin AV. [Evolution of surgical approaches to carotid bifurcation]. Khirurgiia (Mosk) 2024:104-110. [PMID: 38344967 DOI: 10.17116/hirurgia2024021104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
Carotid endarterectomy is preferable for prevention of acute cerebrovascular accident associated with atherosclerotic lesions of internal carotid artery. Modern interest in minimizing local complications and small excisions is also actual in carotid surgery. The authors review the modern literature data on evolution of carotid arteries exposure. Cutaneous mini-incision, transverse skin incision and retrojugular approach are discussed. The authors consider the advantages and possible complications of each technique.
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Affiliation(s)
- A S Kutovaya
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - A L Golovyuk
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - A V Chupin
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
- Russian Medical Academy of Continuous Professional Education, Moscow, Russia
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Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, Kakkos SK, Markus HS, McCabe DJH, Sillesen H, van den Berg JC, Vega de Ceniga M, Venermo MA, Vermassen FEG, Esvs Guidelines Committee, Antoniou GA, Bastos Goncalves F, Bjorck M, Chakfe N, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kolh P, Koncar IB, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Twine CP, Wanhainen A, Document Reviewers, Bellmunt-Montoya S, Bulbulia R, Darling RC, Eckstein HH, Giannoukas A, Koelemay MJW, Lindström D, Schermerhorn M, Stone DH. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg 2023; 65:7-111. [PMID: 35598721 DOI: 10.1016/j.ejvs.2022.04.011] [Citation(s) in RCA: 175] [Impact Index Per Article: 175.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 01/17/2023]
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Jaillant N, Thibouw F, Loucou JD, Pouhin A, Kazandjian C, Steinmetz E. A prospective survey of the incidence of cranial and cervical nerve injuries after carotid surgery. Ann Vasc Surg 2022; 87:380-387. [PMID: 35395376 DOI: 10.1016/j.avsg.2022.03.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 03/21/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To prospectively evaluate the involvement of the cranial nerves and cervical plexus branches during carotid surgery and to look for risk factors. METHODS All patients (n = 50) undergoing carotid endarterectomy between June 1st and October 31st, 2016 in our center were evaluated prospectively. A complete neurological examination was done before the intervention then daily until hospital discharge, and then at 2 months, 6 months and one year. A nasal endoscopy was systematically performed postoperatively before discharge by an ENT specialist. RESULTS Twenty-six patients (52%) had at least one damaged nerve immediately after surgery. There were 15 cases involving the VII nerve (30%), 12 the C2-C3 branches (24%), 7 the XII nerve (14%), and 2 the X nerve (4%). At 2 months, 6 months, and 1 year, 22%, 16%, and 8% of lesions remained, respectively. We found no independent factor for nerve damage at 6 months or 1 year. In case of dysphonia and/or dysphagia without recurrent nerve paralysis, six hematomas and seven laryngeal edemas were identified under nasal endoscopy and all healed without sequelae. CONCLUSIONS This prospective study showed cranial and cervical nerve injury to be much more frequent than expected in the short term, when assessed by independent ENT and nasal endoscopy exam. Though mainly transient, these lesions can cause post-operative functional discomfort and must be disclosed preoperatively to the patient, in view of the judicialization of health care.
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Affiliation(s)
- Noémie Jaillant
- Division of Vascular Surgery, Reunion University Hospital, Reunion, France.
| | | | - Julien Die Loucou
- Division of Vascular Surgery, Dijon University Hospital, Dijon, France
| | - Alexandre Pouhin
- Division of Vascular Surgery, Dijon University Hospital, Dijon, France
| | | | - Eric Steinmetz
- Division of Vascular Surgery, Dijon University Hospital, Dijon, France
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Sinha S, Fok M, Goh A, Gadhvi VM. Outcomes after Transverse-Incision 'Mini' Carotid Endarterectomy and Patch-Plasty. Vasc Specialist Int 2019; 35:137-144. [PMID: 31649900 PMCID: PMC6774431 DOI: 10.5758/vsi.2019.35.3.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 08/13/2019] [Accepted: 08/14/2019] [Indexed: 11/20/2022] Open
Abstract
Purpose Traditional exposure for carotid endarterectomy (CEA) involves making a longitudinal incision parallel to the anterior border of the sternocleidomastoid. Such incisions can be painful, aesthetically displeasing, and associated with a high incidence of cranial nerve injury (CNI). This study describes the outcomes of CEA performed through small (<5 cm long), transversely oriented incisions located directly over the carotid bifurcation, as identified by color-enhanced Duplex ultrasound. Materials and Methods Patient demographics and operative data were collected retrospectively from an in-house database of consecutive vascular patients undergoing CEA with a small transversely oriented incision for both symptomatic and asymptomatic carotid artery stenoses. Results A total of 52 consecutive patients underwent CEA between 2012 and 2016 (median age, 73.5 years; interquartile range, 67–80.3; male/female ratio, 40:12). CEA was performed under regional/local anesthesia (LA) in 48 (92.3%) patients, with 4 (7.7%) being performed under general anesthesia. One patient under LA experienced neurological dysfunction intraoperatively (manifesting as an inability to count out loud) that resolved with insertion of shunt. One patient experienced a transient neurological event (expressive dysphasia) within the immediate postoperative period, which resolved within 6 hours. No in-hospital death or perioperative major adverse cardiovascular events were noted. No persistent CNIs nor bleeding complications necessitating re-exploration were reported. Follow-up data were available for a median period of 3.1 years and for all patients. Three patients experienced strokes following discharge (2 strokes contralateral to and 1 transient ischemic attack ipsilateral to the operated side). Conclusion Small, transversely orientated incisions, hidden within a neck skin crease can be safely performed in the majority of patients undergoing CEA.
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Affiliation(s)
- Sidhartha Sinha
- Department of Vascular Surgery, Basildon Hospital, Basildon, England
| | - Matthew Fok
- Department of Vascular Surgery, Basildon Hospital, Basildon, England
| | - Aaron Goh
- Department of Vascular Surgery, Basildon Hospital, Basildon, England
| | - Vijay M Gadhvi
- Department of Vascular Surgery, Basildon Hospital, Basildon, England
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Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J, Halliday A, Hamilton G, Kakisis J, Kakkos S, Lepidi S, Markus HS, McCabe DJ, Roy J, Sillesen H, van den Berg JC, Vermassen F, Kolh P, Chakfe N, Hinchliffe RJ, Koncar I, Lindholt JS, Vega de Ceniga M, Verzini F, Archie J, Bellmunt S, Chaudhuri A, Koelemay M, Lindahl AK, Padberg F, Venermo M. Editor's Choice - Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 55:3-81. [PMID: 28851594 DOI: 10.1016/j.ejvs.2017.06.021] [Citation(s) in RCA: 789] [Impact Index Per Article: 131.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Antoniou GA, Murray D, Antoniou SA, Kuhan G, Serracino-Inglott F. Meta-analysis of retrojugular versus antejugular approach for carotid endarterectomy. Ann R Coll Surg Engl 2014; 96:184-9. [PMID: 24780780 DOI: 10.1308/003588414x13814021679357] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The retrojugular approach for carotid endarterectomy (CEA) has been reported to have the advantages of shorter operative time and ease of dissection, especially in high carotid lesions. Controversial opinion exists with regard to its safety and benefits over the conventional antejugular approach. METHODS A systematic review of electronic information sources was conducted to identify studies comparing outcomes of CEA performed with the retrojugular and antejugular approach. Synthesis of summary statistics was undertaken and fixed or random effects models were applied to combine outcome data. FINDINGS A total of 6 studies reporting on a total of 740 CEAs (retrojugular approach: 333 patients; antejugular approach: 407 patients) entered our meta-analysis models. The retrojugular approach was found to be associated with a higher incidence of laryngeal nerve damage (odds ratio [OR]: 3.21, 95% confidence interval [CI]: 1.46-7.07). No significant differences in the incidence of hypoglossal or accessory nerve damage were identified between the retrojugular and antejugular approach groups (OR: 1.09 and 11.51, 95% CI: 0.31-3.80 and 0.59-225.43). Cranial nerve damage persisting during the follow-up period was similar between the groups (OR: 2.96, 95% CI: 0.79-11.13). Perioperative stroke and mortality rates did not differ in patients treated with the retrojugular or antejugular approach (OR: 1.26 and 1.28, 95% CI: 0.31-5.21 and 0.25-6.50). CONCLUSIONS Currently, there is no conclusive evidence to favour one approach over the other. Proof from a well designed randomised trial would help determine the role and benefits of the retrojugular approach in CEA.
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Affiliation(s)
- G A Antoniou
- Central Manchester University Hospitals NHS Foundation Trust, UK.
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Is the retrojugular approach safer than the conventional approach for carotid endarterectomy? World J Surg 2009; 33:1533-7. [PMID: 19424749 DOI: 10.1007/s00268-009-0052-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The retrojugular approach is promoted as an alternative to traditional antejugular carotid endarterectomy. Absence of named posterior venous branches and ease of distal internal carotid dissection reduce time for carotid exposure together with improved distal exposure. However, a higher incidence of local nerve injury and persistent hoarse voice has been reported. We compare the incidence of these and other complications for the antejugular and retrojugular approaches. DESIGN This is a nonrandomised retrospective review of prospectively collected data on consecutive patients undergoing carotid endarterectomy. RESULTS Our 178 patients formed two groups who were homogeneous in terms of sex and age. Mean operative times, patch usage, and general/local anaesthesia did not differ significantly for the two groups. Postoperative complications including transient ischemic attack (TIA), major stroke, or death; hypertension; miosis; and hypoglossal injury were similar for the two groups. However, there was a significantly increased incidence of persistent hoarse voice (p < 0.05) in the retrojugular group. CONCLUSIONS Reports of increased incidence of persistent hoarse voice associated with the retrojugular approach to carotid endarterectomy are supported by our findings, which point to a learning curve effect. A randomized controlled trial would be necessary before any strong recommendation could be made for or against the retrojugular approach.
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Beasley WD, Gibbons CP. Cranial nerve injuries and the retrojugular approach in carotid endarterectomy. Ann R Coll Surg Engl 2008; 90:685-8. [PMID: 18828964 DOI: 10.1308/003588408x318138] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION This is a retrospective case series analysis to compare the incidence of cranial nerve injuries in carotid endarterectomy by the retrojugular and anteromedial approaches. PATIENTS AND METHODS Data were extracted from a prospectively collected database. Ninety-one retrojugular carotid endarterectomies were compared with 145 anteromedial carotid endarterectomies. All were performed under local anaesthesia and used the eversion technique. Data were analysed using the chi-squared test. RESULTS Nine (3.8%) cases were complicated by cranial nerve injuries. In four cases, multiple nerves were involved. In total, 13 (5.5%) cranial nerves were injured. The affected nerves were: two (0.8%) marginal mandibular, two (0.8%) laryngeal, three (1.2%) accessory and six (2.5%) hypoglossal. There was no statistically significant difference in total or specific cranial nerve injuries between the two surgical approaches. CONCLUSIONS The risk of cranial nerve injuries was similar following either the retrojugular or anteromedial approach. Accessory nerve injuries were only seen in the retrojugular approach but this did not reach statistical significance.
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Retrojugular versus Ventrojugular Approach to Carotid Bifurcation for Eversion Endarterectomy: A Prospective Randomized Trial. Eur J Vasc Endovasc Surg 2008; 35:190-5; discussion 196-7. [DOI: 10.1016/j.ejvs.2007.10.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2007] [Accepted: 10/20/2007] [Indexed: 11/21/2022]
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Pintér L, Cagiannos C, Bakoyiannis CN, Kolvenbach R. Hybrid treatment of common carotid artery occlusion with ring-stripper endarterectomy plus stenting. J Vasc Surg 2007; 46:135-9. [PMID: 17606131 DOI: 10.1016/j.jvs.2007.01.062] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2006] [Accepted: 01/25/2007] [Indexed: 11/18/2022]
Abstract
Symptomatic occlusion of the common carotid artery with preserved circulation in the internal carotid artery is an uncommon occurrence. We describe a hybrid technique whereby a patient was treated with eversion carotid bifurcation endarterectomy, fluoroscopically guided retrograde ring-stripper common carotid endarterectomy, and stenting of residual stenosis in the disobliterated artery. Successful recanalization was achieved without adverse anatomic or neurologic sequelae. The patient remains asymptomatic with a radiographically patent reconstruction at 1 year. This combination of endovascular and open surgery enables the surgeon to address long occlusions of the common carotid arteries with control of the distal and proximal endarterectomy margins and obviates the need for general anesthesia or sternotomy.
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Affiliation(s)
- László Pintér
- Department of Vascular Surgery and Endovascular Interventions, Augusta Hospital, Amalien Strasse 9, 40472 Düsseldorf, Germany.
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Tubbs RS, Shoja MM, Acakpo-Satchivi L, Wellons JC, Blount JP, Oakes WJ, Iskandar BJ. Exposure of the V1–V3 segments of the vertebral artery via the posterior cervical triangle: a cadaveric feasibility study. J Neurosurg Spine 2006; 5:320-3. [PMID: 17048768 DOI: 10.3171/spi.2006.5.4.320] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Surgical exposure of the extracranial part of the vertebral artery (VA) is occasionally necessary. Historically, the greater portion of the extracranial portion of the VA has been approached by traversing the anterior cervical triangle. The authors speculated that this entire segment of the VA could be reached with equal efficacy via the posterior cervical triangle (PCT).
Methods
Six adult cadavers underwent dissection of the left and right VAs via the PCT. The entire extracranial VA was easily exposed through this approach. Only three of 12 sides required the transection of the clavicular head of the sternocleidomastoid muscle for exposure of the most proximal segment of the VA as it originated from the subclavian artery. No gross injury to the VA or other regional vessels or nerves was noted.
Conclusions
The authors found that the extracranial VA can be exposed easily through the PCT. Following confirmation of this technique in vivo, this approach may be added to the surgeon’s armamentarium for exposing the extracranial segment of the VA.
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Affiliation(s)
- R Shane Tubbs
- Department of Cell Biology, University of Alabama at Birmingham, Alabama, USA.
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Onwudike M. The retrojugular approach to carotid endarterectomy--a safer technique. Eur J Vasc Endovasc Surg 2005; 31:336. [PMID: 16359886 DOI: 10.1016/j.ejvs.2005.10.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2005] [Accepted: 10/24/2005] [Indexed: 11/25/2022]
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