Complication Rates After Left- Versus Right-Sided Carotid Endarterectomy

Abstract

Background-Studies suggest that the side of carotid endarterectomy (CE) may influence the rate of postoperative complications. We sought to clarify this by (1) analysis of individual-level data from 3 large studies and (2) systematic review and meta-analysis of additional published descriptions of outcomes by side. Methods and Results-The Western Canada Carotid Endarterectomy (WCCE) study (nϭ3164) was analyzed for outcomes by side along with data from the North American Symptomatic Carotid Endarterectomy Trial (NASCET; nϭ1415), and the ASA [Acetylsalicylic Acid] in Carotid Endarterectomy Trial (ACE; nϭ2469). Pooled analysis of individual-level data from these three studies allowed calculation of rate ratios for stroke or death by side. Medline and EMBASE were searched to identify additional studies reporting CE outcomes by side, and an overall risk ratio for outcomes by side was determined with fixed-effects meta-analysis. The WCCE in-hospital stroke or death rates for left and right-sided CE were 3.72% and 3.07%, respectively (Pϭ0.27). A pooled analysis of the NASCET and ACE trials also revealed higher stroke or death rates for left-sided CE (5.39% versus 2.96%; PϽ0.001). The corresponding risk-adjusted rate ratios for stroke or death for left-versus right-sided surgery were 1.22 (95% CI, 0.83 to 1.77) for WCCE and 1.82 (1.32 to 2.50) for the pooled NASCET and ACE trials. Systematic review of the literature identified 2 additional studies. Meta-analysis of all 5 available studies yielded a corresponding pooled rate ratio for stroke or death of 1.36 (1.18 to 1.56). Conclusions-Left

Recurrence and Progression of Head and Neck Paragangliomas after Treatment

“…Several studies within the orthopedic literature have demonstrated statistically different outcomes related to laterality and surgeon handedness 32 , 33 . Differences have also been shown regarding laterality of carotid endarterectomy 34 , 35 . Further research is needed to investigate the reproducibility of this result.…”

“…32,33 Differences have also been shown regarding laterality of carotid endarterectomy. 34,35 Further research is needed to investigate the reproducibility of this result.…”

Etiology and Time to Presentation of Unilateral Vocal Fold Paralysis

“…There also may be a role in surgeon handedness, making left-sided carotid endarterectomies more technically difficult for right-handed surgeons. 25…”

Carotid Revascularization: An Update

“…73 Already mentioned is the higher peri-operative stroke risk associated with a left, as opposed to right, CEA. 59 Although the cause for this side discrepancy seen in several large trials is speculative, the authors suggest that surgeon handedness and intraoperative ergonomics might account for their findings. The implications of this with respect to the surgical procedure are discussed in the preceding section.…”

“…Although complications after CEA will be discussed in the next section, it should be mentioned that there is evidence that left-sided CEA is consistently associated with higher postoperative stroke rates, and it is speculated that this is due to the less favorable ergonomics of right-handed surgeons performing a left-sided repair where the distal exposure and plaque is relatively more difficult to reach (requiring internal rotation of the surgeon's dominant right hand) and therefore make perfect. 59 Use of the operating microscope as a diploscope, where the surgeon and assistant are at 180º from each other, requires an almost flat operating field achievable only with general anaesthetic. This not only allows best visualization of the distal exposure, but also allows the primary surgeon to work from either the right or left side for either a right or left CEA, depending on which side proves most physically comfortable for plaque removal and artery repair.…”