The hostile neck does not increase the risk of carotid endarterectomy
Article Outline
- Abstract
- Patients and methods
- Results
- Discussion
- Conclusions
- Author contributions
- Acknowledgment
- References
- Copyright
Introduction
Hostile neck anatomy is assumed to be associated with increased surgical risk for patients undergoing carotid endarterectomy (CEA) and is often considered a reason to choose carotid stenting or medical management. This retrospective case–control study evaluated whether, and how much, anatomically hostile necks represent a condition of higher surgical risk of early and late mortality and major or minor morbidity.
Methods
The data for 966 homogeneous CEA patients was prospectively entered in a computer database. Seventy-seven had a hostile neck anatomy due to previous oncologic surgery or neck irradiation, restenoses after CEA, high carotid bifurcation, or bull-like and inextensible neck. A case-control matched-pair cohort study considered sex, age (5-year intervals), and year of operation. Regional anesthesia was used for all operations for atherosclerotic stenosis ≥70%, conforming to the European Carotid Surgery Trial (ECST) in symptomatic and asymptomatic patients, at a single center and by one surgeon or under his direct supervision.
Results
The hostile neck patients and the control group were matched for age, sex, carotid-related symptoms, degree of stenoses, and main risk factors for cardiovascular diseases. Intraoperative variables were substantially equivalent in the two groups; however, procedure length and clamping time were, respectively, about 22 minutes (P = .0001) and 7 minutes longer (P = .01) in the hostile neck group. Rates of postoperative mortality and neurologic events were equivalent. Peripheral nerve lesions were multiple and significantly more frequent in the hostile neck patients (21% with ≥1 cranial nerve lesion vs 7% of controls, P = .03), yet all were transient and limited to a few months. The subgroups of patients with hostile neck, restenoses, and bull-like inextensible necks required the longest operative and clamping time, and those with bull-like and high bifurcation had the most frequent cranial nerve dysfunctions. At the respective follow-up of 47 and 45 months, survival curves (P = .48) and the incidence of restenoses and fatal and nonfatal strokes were similar (5 and 4, respectively).
Conclusions
Hostile necks led to more complex CEA procedures but without substantial consequences in early and late morbidity and mortality. Most patients with hostile neck can undergo CEA at low risk, with the benefit of effective long-lasting stroke prevention similar to standard patients. In our opinion, the more frequent but temporary cranial nerve dysfunctions that occur are not sufficient to consider hostile neck patients noneligible for CEA.
Landmark prospective randomized clinical trials have definitively shown that carotid endarterectomy (CEA) offers a significant therapeutic advantage compared with optimal medical therapy, if perioperative mortality and major morbidity are <6% in symptomatic and 3% in asymptomatic patients.1, 2, 3, 4 In reality, patients empirically estimated at high risk for surgery—particularly for advanced age, comorbidities, and cervical abnormalities—were excluded from these and other trials. In the course of the last 15 years, however, modern medical therapies have substantially improved the control of atherosclerotic disease by means of statins and more effective antihypertensive and antiplatelets drugs.5, 6, 7 Moreover, carotid angioplasty with stenting (CAS) has gained a growing and uncontrolled popularity on the assumption that minor invasiveness is equal to minor risk.
Unfortunately, some trials have shown unexpected risks for CAS in some cohorts of patients estimated at high medical8 and surgical risk; for example, elderly people (Carotid Revascularization Endarterectomy vs. Stent Trial)9 and patients with restenoses after CEA.10, 11 The Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis (EVA-3S) comparative trial was prematurely interrupted due to excessive risks in the patients treated with CAS,12 and the Stent-Supported Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy (SPACE) comparative trial concluded that the indiscriminate widespread use of CAS is not justified.13 Finally, very recent meta-analyses did not support the superiority of CAS over CEA.14, 15, 16, 17, 18
Thus, in such a confusing situation where clarifying studies comparing modern treatment modalities are still awaited, it is worthwhile to ascertain which single category of patients may benefit more from one kind of treatment or another, depending on the specific procedural risks. In particular, patients with altered and unfavorable cervical anatomy due to previous carotid or oncologic surgery, cervical irradiation, abnormally high carotid bifurcation, and very short and inextensible neck, may pose significant technical challenges in terms of operating technique increasing the number of complications.19 Several retrospective studies from surgical series have investigated the problem,11, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 but only considered the main early outcomes of postoperative mortality and major neurologic morbidity. Other periprocedural variables, minor complications, and late results, such as survival, late neurologic events, and restenoses disclosing perhaps directly or indirectly a higher procedural difficulty, have never been properly quantified, nor have safer and long lasting results been proved for patients with a hostile neck treated with CAS or medical therapy.
The purpose of this study was to quantify the effect of hostile neck anatomy on early and late outcomes of CEA. To this end we designed a retrospective case–control study using prospectively gathered data from the computer database of our center's 20-year experience with CEA.
Patients and methods
A prospective database of patients operated on for cerebrovascular diseases recorded from 1989 until June 2008 was consulted. From 1246 revascularization procedures, the following were excluded: the first 53 patients operated on during the first 3 years of surgical activity because of the learning curve), 182 operated on in consultation at other hospitals with different attending modalities, and 45 CEAs performed during major reconstructions of supra-aortic trunks because of greater surgical complexity. The remaining 966 CEAs were all performed by the same senior surgeon or under his direct supervision since 1992, at the same institution and with the same techniques, although these have obviously evolved during the 16-year period.
The indication for surgery was atherosclerotic stenosis ≥70% (conforming to European Carotid Surgery Trial [ECST]), both in symptomatic and asymptomatic patients, and ≥50% when an ulcer was clearly evident in a symptomatic patient or when the contralateral carotid was occluded. All surgical procedures were performed with regional anesthesia with deep (C2 to C4) and superficial cervical plexus block or cervical epidural anesthesia in the C7 to T1 intervertebral space (awake patient), the latter being used from 1992 to 1994 during an unpublished comparative study.
The surgical technique followed standard safety rules entailing the preventive isolation of the hypoglossal nerve, isolation of the carotid artery without manipulation of the atherosclerotic plaques, dissection of the carotid bifurcation only after cross-clamping under systemic heparinization, the use of a selective shunt based on patient response, direct visualization of the extremities of the endarterectomy, accurate removal of any residual flaps with the fixation of a possible distal dissection, and systematic patch closure after open technique (with possibly a transverse plication if the endarterectomized artery was excessively redundant) or reimplantation after the eversion technique. The patient's clinical condition was monitored hourly for the first 24 hours after the procedure, usually in the surgical ward.
The selection criteria used in the present study were as follows:
Other anatomic abnormalities were excluded, in particular (1) low bifurcation traditionally not representing a challenge to surgery; (2) previous thyroid or parathyroid surgery regarding only the anterior neck, unless associated with radical lymphectomy; and (3) contralateral carotid occlusion and recurrent laryngeal nerve palsy, unlike the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) study,31 because these conditions represent an adjunct risk not anatomically related to the field of surgery.
A case–control matched-pair cohort study was conducted. All patients satisfying the selection criteria were placed in the hostile neck group and were consecutively matched with an equal number of patients randomly chosen out of the possible pool for sex, age (5-year intervals), and year of operation. Symptoms, degree of stenosis, and cardiovascular risk factors were not used as matching criteria.
In addition to the database of the selected and control patients, we reviewed hospital medical records, descriptions of the surgical procedures from the operative registers, daily hospital notes, operative discharge summaries (including notes from the surgeon and medical consultations), and records from the follow-up, which were planned at 1, 3, and 6 months, and then yearly. Perioperative outcome measures included cranial nerve injuries, stroke, transient ischemic attack, cardiac events, and death occurring ≤30 days from the procedure.
Clinical signs and symptoms of neurological deficit were systematically searched in the postoperative period, carefully described by the operator or the surgeon on call, and commented on at discharge. Cranial nerve injuries were defined clinically or after consulting with an otolaryngologist, with or without laryngoscopy. Symptoms such as ipsilateral lip drop and involuntary drooling were attributed to dysfunctions in the marginal mandibular branch of the facial nerve; ipsilateral deviation of the tongue, inarticulate speech, and clumsy mastication to the hypoglossal nerve; hoarseness and difficulty coughing effectively to the recurrent laryngeal nerve; voice fatigue and loss of high-pitch phonation to the superior laryngeal nerve; difficulty in swallowing solid food and nasopharyngeal reflux of fluids with possible aspiration to the glossopharyngeal nerve; and sensory loss, paresthesia, and dysesthesia in the inframandibular region, earlobe, and scalp to the greater auricular nerve. Dysfunctions regressing within the day of operation were not considered because they were attributed to additional local infiltrations of anesthetics.
The entity of symptoms was determined at follow-up according to the patient's description and the surgeon's physical examination. Stroke was defined in terms of a new neurologic event lasting >24 hours and was classified as minor (lasting >24 hours and cleared at 30 days), major (symptoms persisting for >1 month), and lethal. Transient ischemic attack was defined in terms of a new neurologic focal event from which the patient would completely recover ≤24 hours. In the case of specific symptoms or uncertainties, the patient was examined by a neurologist and underwent computed tomography (CT) scan or magnetic resonance imaging (MRI) if necessary. Myocardial infarction was diagnosed on the occurrence of a new Q-wave in two leads or the presence of elevated enzymes. Cardiac enzyme levels and electrocardiogram were routinely assessed in the postoperative setting and subsequently obtained only in response to appropriate patient signs or symptoms.
The reported long-term outcomes included carotid bifurcation restenosis, permanent nerve injuries, cardiac and neurologic events, and death. Late results were analyzed, and deficits lasting >2 years were considered permanent. Restenosis was defined as carotid stenosis >30% after intervention at the follow-up duplex examination, considering the area of the residual lumen related to the supposed lumen of the vessel at the level of the stenosis conforming to ECST. Fatal stroke was defined as death attributed to ischemic or hemorrhagic stroke. A fatal cardiac event was defined as death attributed to acute myocardial infarction or cardiac failure. These events were recognized through descriptions in the computerized medical records by the surgeon, neurologist, or otolaryngologist, as well as by results of head CT or brain MRI.
Patients whose last follow-up dated back 1 year were contacted by phone and recalled for ambulatory clinical and duplex examination. Information on dead patients or those lost to follow-up was obtained through relatives, a family doctor, or the registry office.
Data were processed using the Open Stat 4 software (by Bill Miller, Iowa State University). The two groups were compared with the t test for continuous data and the χ2 test for categoric data. The Kaplan-Meier analysis was used for the survival rate, and survival curves were compared with the log-rank test. The level of significance was assumed as P < .05.
Results
Patients
We identified 77 patients as having hostile neck and divided them into four main subgroups:
Patients with hostile neck anatomy were statistically equivalent to the control group in age, gender, symptom status, degree of stenosis, and cardiovascular risk factors (Table I).
Table I. General data and cardiovascular risk factors in the two groups
| Variable | Hostile necks | Controls | P (t or χ2 test) |
|---|---|---|---|
| Total patients, No. | 77 | 77 | |
| Symptomatic at diagnosis | 50 | 55 | .38 |
| Male/female (ratio) | 51/26 (1.96:1) | 51/26(1.96:1) | … |
| Age, y | .85 | ||
| Mean ± SD | 69.7±7.6 | 69.5±6.5 | |
| Median (range) | 70(55-92) | 70(51-82) | |
| Lipidemia, No. | .29 | ||
| No data | 9 | 8 | |
| Absent | 36 | 25 | |
| Hypertriglyceridemia | 2 | 5 | |
| Hypercholesterolemia | 18 | 29 | |
| Mixed | 12 | 10 | |
| Diabetes mellitus, No. | .91 | ||
| No data | 3 | 5 | |
| Absent | 50 | 50 | |
| Diet control | 12 | 11 | |
| Oral hypoglycemic therapy | 9 | 7 | |
| Insulin therapy | 3 | 4 | |
| Systolic pressure, No. | .85 | ||
| No data | 5 | 4 | |
| <150 mm Hg | 45 | 49 | |
| >150 mm Hg | 26 | 24 | |
| Abnormal | 1 | … | |
| Smoking, No. | .96 | ||
| No data | 12 | 9 | |
| Absent | 22 | 23 | |
| 1-10 cigarettes/d | 1 | 3 | |
| 10-20 cigarettes/d | 2 | 2 | |
| >20 cigarettes/d | 8 | 8 | |
| Ex-smoker | 32 | 32 | |
| Cardiac diseases, No. | .21 | ||
| No data | 1 | 5 | |
| Absent | 32 | 26 | |
| Valve disfunction | 5 | 2 | |
| Myocardial infarction | 11 | 17 | |
| Angina | 7 | 4 | |
| Serious cardiac dilatation | — | 4 | |
| Arrhythmia | 2 | 3 | |
| Altered conduction | 8 | 4 | |
| Hypertensive cardiomyopathy | 11 | 9 | |
| Other | … | 3 |
Operative details
A comparison of operative data for the hostile neck anatomy groups and control patients is summarized in Table II. No statistically significant differences were noted in anesthetic management, operative technique, carotid reconstruction techniques, shunt requirement, blood loss, or hospital stay. Significant differences were, however, noted in total operative and clamp time.
Table II. Type of anesthesia and surgical procedure
| Variable | Hostile necks | Controls | P (t or χ2 test)a |
|---|---|---|---|
| Patients, No. | 77 | 77 | |
| Anesthesia, No. | .48 | ||
| Deep, superficial plexus block | 67 | 62 | |
| Cervical epidural, interscalenic, local | 8 | 14 | |
| Conversion to general | 2 | 1 | |
| Carotid endarterectomy, No. | .97 | ||
| Open technique | 47 | 47 | |
| Eversion technique | 26 | 27 | |
| Resection | 4 | 3 | |
| Reconstruction, No. | .39 | ||
| Direct closure | 3 | 2 | |
| Vein patch | 6 | 1 | |
| PTFE patch | 8 | 8 | |
| Dacron patch | 35 | 36 | |
| Bypass/other | 1 | 4 | |
| Reimplantation | 24 | 26 | |
| Need for selective shunt, No. | 8 | 8 | … |
| Operative time, min | |||
| Mean ± SD | 128.9±35.2 | 106.1±28.4 | .0001 |
| Median (range) | 120(70-220) | 100(60-180) | |
| Clamping time, min | |||
| Mean ± SD | 52.3±20.1 | 45±15.2 | .01 |
| Median (range) | 50(20-120) | 40(20-95) | |
| Blood loss, mL | |||
| Mean ± SD | 120.6±179.5 | 104.4±154.8 | .58 |
| Median (range) | 50(10-1000) | 50(10-900) | |
| Post-op hospital stay, d | |||
| Mean ± SD | 4.1±2.3 | 4.1±2.2 | .44 |
| Median (range) | 4(2-13) | 4(2-12) |
aStatistical significance set at P < .05. |
Perioperative outcome (Table III) was equivalent in the two groups. Only dysfunctions due to cranial nerve injuries or their branches were significantly more frequent and longer lasting in the hostile neck patients. Nevertheless, all lesions were temporary and, above all, with no clinical consequence. The number of cranial nerve injuries per patient was significantly higher in the hostile neck group.
Table III. Perioperative complications
| Complication | Hostile necks | Controls | P (t or χ2 test)a |
|---|---|---|---|
| Patients, No. | 77 | 77 | |
| Deaths, No. | 1b | 1b | … |
| Congestive heart failure, No. | 1c | 1c | … |
| Transient ischemic attack, No. | 1 | 1 | … |
| Stroke, minor, No. | 1 | 0 | .15 |
| Redo surgery for hematoma, No. | 2 | … | .31 |
| Cranial nerves dysfunction, No. | 24 in 16 pts | 7 in 5 pts | .82 |
| Symptoms duration, mon | |||
| Mean ± SD | 4.6±5.5 | 4.1±2.4 | |
| Median (range) | 2(1-27) | 3(2-8) | |
| Nerve dysfunction duration, median (mean ± SD) | |||
| Facial, mandibular branch | 3(1.5±0.5) | 1 | .31 |
| Superior laryngeal | 2(1.3±0.5) | … | .31 |
| Deglutition deficit | 8(4.1±3.3) | 2(4.0±2.8) | .04 |
| Recurrent laryngeal | 5(3.0±2.4) | 1 | .02 |
| Hypoglossal | 6(8.8±8.5) | 3(5.5±2.1) | .31 |
| Nerves involved per patient | |||
| None, No.(%) | 61(79.2) | 72(93.6) | .03 |
| One nerve, No.(%) | 8(10.4) | 3(3.8) | |
| Two nerves, No.(%) | 8(10.4) | 2(2.6) |
aStatistical significance at P < .05. |
bBoth deaths were a result of myocardial infarction. |
cBoth events were failures. |
Late outcome
Detailed data were collected for an equivalent number of patients and for a similar follow-up period in the two groups (Table IV). The log-rank test showed no statistical difference in survival between the groups (Fig). Fatal neurologic and cardiac death rates were similar for the two groups, and all strokes were ischemic except one hemorrhagic stroke in the hostile neck group. Late nonfatal neurologic events were also statistically similar. No restenosis progressed to >50%.
Table IV. Long-term mortality and morbidity
| Variable | Hostile necks | Controls | P (t or χ2 test)a |
|---|---|---|---|
| Patients, No. | 75/77 | 74/77 | |
| Follow-up, mon | |||
| Mean ± SD | 47.3±37.5 | 45.2±39.2 | .74 |
| Median (range) | 40(0-156) | 40(0-193) | |
| Mortality, No. | 12 | 15 | .52 |
| Stroke | 2 | 3 | |
| Cardiac events | 4 | 7 | .76 |
| Noncardiovascular | 6 | 6 | |
| Morbidity, No. (timing) | |||
| Nonfatal strokes | 3(36mon) | 1(72mon) | .31 |
| TIAs | 1(11mon) | 1(1mon) | … |
| Nonfatal cardiac events | 5(35mon) | 7(45mon) | .17 |
| Restenosis <50% | 1(30mon) | 2(45mon) | .55 |
aStatistical significance at P < .05. |
Fig.
Kaplan-Meier survival curves for the hostile neck group (red line) and the control group (blue line) are presented with the 95% confidence intervals (gray lines). Log-rank P = .78.
Analyses for the subgroups
When the four subgroups of hostile neck patients were considered separately, analyses showed that the outcome of patients with previous oncologic surgery or neck radiation was very similar to the control group (Table V). Restenoses and bull-like inextensible necks required the longest operative and clamping times, and bull-like necks and high bifurcation had the most frequent cranial nerve dysfunctions.
Table V. Analyses of the subgroups compared with the controls (see second columns in Table II, Table IV)
| Variablea | Previous surgery | Pb | Restenosis | Pb | High bifurcation | Pb | Bull-like and inextensible neck | Pb |
|---|---|---|---|---|---|---|---|---|
| Total patients | 11 | 23 | 35 | 8 | ||||
| Operation time, min | 114.3±30.8 | .09 | 133.5±34.2 | .001 | 124.4±35 | .01 | 141.6±47.9 | .007 |
| Clamping time, min | 45.2±8.2 | .97 | 58.1±17.1 | .003 | 49.8±21 | .22 | 57.5±34 | .09 |
| Need for shunt | … | .26 | 3 | .72 | 3 | .76 | 2 | .22 |
| Blood loss, mL | 74.2±144.6 | .62 | 126±233.9 | .63 | 121.2±132.9 | .63 | 150±207.6 | .47 |
| Clamping time, min | 45.2±8.2 | .97 | 58.1±17.1 | .003 | 49.8±21 | .22 | 57.5±34 | .09 |
| Hospital stay, d | 4.7±3.4 | .35 | 3.4±1.7 | .008 | 3.6±2.1 | .006 | 4.1±2 | .33 |
| Cranial nerve dysfunction, No. | ||||||||
| Facial, mandibular branch | … | .70 | 1 | .35 | 1 | .56 | 1 | .05 |
| Superior laryngeal | … | … | 2 | .008 | … | … | … | … |
| Deglutition deficit | 1 | .26 | 2 | .19 | 3 | .15 | 2 | .004 |
| Recurrent laryngeal | 0 | .70 | 1 | .35 | 3 | .04 | 1 | .04 |
| Hypoglossal | 1 | .44 | 1 | .93 | 3 | .31 | 1 | .27 |
| Nerves per patient | ||||||||
| None | 10 | .44 | 18 | .01 | 28 | .01 | 5 | .008 |
| One | … | 3 | 4 | 1 | ||||
| Two | 1 | 2 | 3 | 2 | ||||
| Stroke (timing) | … | .70 | 2(47 mon) | .06 | .49 | 1(15 mon) | .04 | |
| TIA (timing) | … | .70 | … | .58 | 1(11 mon) | … | … | .51 |
| Cardiac events (timing) | … | .29 | … | .13 | 4(36.5 mon) | .70 | 1(29 mon) | .75 |
| Restenosis <50% (timing) | … | .58 | 1(30 mon) | .66 | .33 | … | .64 |
aContinuous data are presented as mean ± SD; categoric data are presented as the number. |
bStatistical significance set at P < .05. |
Discussion
A consistent definition of “hostile” neck does not exist yet, and the concept of “technically difficult” is largely subjective. Nevertheless, in surgical practice, anatomic abnormalities (physiologic or pathologic, acquired or congenital), fibrosis secondary to surgery, and infections or irradiation may result in a more difficult dissection with possible injury to surrounding tissues, particularly the cranial nerves and other cervical branches of the somatic nerves. Similarly, more vascular manipulation and limited exposition may decrease technical accuracy, thus favoring thromboembolic complications and suboptimal reconstruction. Finally, prolonged anesthesia and procedural time may be followed by systemic complications.
Our study has two major limitations. First, because our data are drawn from a single institution's experience, our results and conclusions may not pertain to other practice settings. Second, we had relatively small numbers of patients with hostile neck anatomy and low adverse event rates, and so are unable to detect small outcome differences should any exist.
According to our inclusion criteria, approximately 7% of carotid stenoses amenable to surgery may reside in a hostile neck. Our intraoperative data generally show substantial equivalence between patients with hostile neck and standard patients. Mean operative time was significantly longer (22 minutes) in the studied group, although this does not seem to be crucial in increasing the physiologic risks. The difference is more attributable to vessel dissection than to the endarterectomy and reconstruction phase, although a slightly longer clamping time (8 minutes) was reported.
These data are confirmed in the restenosis, high bifurcation, and bull-like and inextensible neck subgroups, for which operating time was respectively 27, 18, and 35 minutes longer than that of the control group. In particular, the high bifurcation and bull-like and inextensible neck subgroups usually required a more extensive dissection, with mobilization of distal structures such as the hypoglossal nerve, ligation of the occipital branch of the external carotid artery, and occasionally, division of the digastric muscle, fracture of the styloid process, and subluxation of the mandible. Only patients with restenoses reported longer cross-clamping time, suggesting a more difficult or complex endarterectomy and reconstruction.
Conversely, patients with previous oncologic surgery, with or without associated irradiation, had an overall operating time equal to controls, indicating that the CEA procedure is only marginally affected by previous laryngectomy, tracheostomy, or radical neck dissection. In this context, the exact role of neck irradiation cannot be deduced because this has been nearly always associated with surgery. Furthermore, operative blood loss and the need for reoperation for hematoma are comparable, suggesting that the anatomic abnormalities being considered do not increase the risk of hemorrhage, even though we did not usually neutralize systemic heparinization after clamping release.
Mean hospital stay is equivalent and may appear very long when taking into consideration present hospital discharge times. This is mainly due to the long period covered by this series. In fact, during the first years of the study, patients remained in the hospital until the cutaneous stitches were removed. At present, patients are usually discharged on postoperative day 2, after skin clips are removed and replaced by Steri-Strips (3M, St. Paul, Minn); therefore, the current postoperative hospital stay is about 36 to 40 hours.
With the above-mentioned limitations of the present study, postoperative data indicate equivalence for death and cardiac and central neurologic events ≤30 days from the operation. Adverse events reported in both groups are much less frequent than the accepted standard for this surgery1, 2, 3, 4 according to other retrospective studies from single series.20, 21, 24, 25, 26, 27, 28, 29, 30 In particular, two postoperative deaths were due to cardiac complications, and no lethal or major stroke was reported in the study or control group. These are in fact the main evaluation criteria being considered in major international studies comparing CEA with optimal medical therapies and more recently with CAS. Only temporary cranial nerve dysfunction was significantly more frequent (20.8%) and more frequently involved two nerves (10.4%) when the hostile neck group was compared with the control group. High bifurcations and bull-like or inextensible necks proved to be the anatomic conditions leading to the highest risk for cranial nerve injuries.
Lesions were likely due to excessive retraction or electrocautery in a narrow surgical field. Almost all dysfunctions were limited to minor functional impairments such as tongue or mouth deviation, difficulty in deglutition and drinking, and hoarseness. Although in our global series we observed at least two major and definitive lesions, all lesions of the patients reported here resolved in a few weeks or months—with the exception of 27 months for a tongue deviation— and no major complication such as aspiration was reported.
Cranial nerve palsy after CEA has been reported with extremely variable rates in various series, probably indicating different detection methods, and is usually considered minor and transient. A very recent literature review calculated a 9% mean risk (range, 2%-27%) of temporary palsy,32 and two large, recent collective series reported a similar rate of somewhat higher than 5%, with only 0.5% lasting more than a few months.23, 33 Outside of standard conditions, cranial nerve deficits may be more frequent. In another recent series, 26 lesions were observed in 19 of 89 patients who underwent reoperations for restenosis.22 In irradiated necks, soft-tissue fibrotic changes and more extended atherosclerotic lesions34, 35, 36, 37 probably explain a greater risk of peripheral nerve lesions, as reported in two small series of 11 and 14 patients treated with CEA, in whom no central neurologic events were reported.26, 27 Only sporadic radiation lesions were treated with CAS however,38, 39, 40, 41 thus precluding a comparison between surgical and endovascular treatments of radiation-induced carotid stenosis.
High bifurcations may raise greater problems in adequately exposing the distal internal carotid artery and obtaining an optimal distal endarterectomy before reconstruction. A recent anatomic study confirmed that in this situation, the hypoglossal nerve would pass very close to the carotid bifurcation.42 Nevertheless, in small groups extrapolated from large surgical series, unfavorable results were not reported in these patients.29, 30 To our knowledge, no reports have been published regarding very short, bull-like and inextensible necks.
Finally, overall the mortality rate and causes of death at nearly 4 years of follow-up are very similar in the two groups. Particularly, the subgroup with previous oncologic surgery and radiotherapy did not present an exceedingly high cancer-related mortality, confirming the suitability of surgery in these patients with a possibly reduced life expectancy. The rate of late fatal strokes and minor nonfatal strokes in the hostile neck patients showed no statistically significant differences compared with the control patients: all events occurred 3 to 5 years after surgery. In the subgroup analysis, an excessive 12.5% risk of late stroke seems to be clear in the bull-like and inextensible neck subgroup (P = .04), although these events were not related to any duplex-detected carotid lesion. However, conclusions drawn from these subgroup data are suspect because of the very small numbers of subjects and events in each subgroup.
Conclusions
Nearly all variables examined indicate substantial equivalence in early and late outcomes in our practice when CEA patients with and without hostile neck anatomy are compared. Our findings lead to the conclusion that a hostile neck should not necessarily disqualify patients from consideration for CEA. An increased frequency of cranial nerve injuries was noted in the hostile neck group, but it is questionable whether morbidity related to cranial nerve injury is sufficiently compelling to direct patients with hostile necks toward carotid stenting or medical management.
Carotid restenosis, prior cervical oncologic surgery with and without associated radiation therapy, high carotid bifurcation, and a short or inextensible neck represent frequently encountered conditions that render CEA more complex and lead to longer surgical time. In our practice, however, these conditions do not result in an increase in major perioperative morbidity or mortality. Our data suggest that most patients with hostile neck anatomy can undergo CEA with an acceptably low risk for early or late complications and that the benefit of CEA in providing effective and durable stroke prevention is not compromised in these patients.
Well-trained and experienced surgeons should not consider hostile neck anatomy a contraindication to CEA. Cranial nerve injury is the only adverse outcome significantly more common in patients with hostile neck anatomy, and such injuries are usually transient. Obviously, the increased risk of such injuries should be thoroughly discussed with all patients scheduled for CEA, especially those with hostile neck anatomy.
Author contributions
We are particularly grateful to Claudio Campagnaro for his careful English language revision.
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Competition of interest: none.
PII: S0741-5214(08)02292-1
doi:10.1016/j.jvs.2008.12.053
© 2009 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
