Cranial Nerve Injuries and the Retrojugular Approach in Carotid Endarterectomy

Abstract

Ann RC oll Surg Engl 2008; 90:6 85-688 685In the 'standard'approach to the carotid bifurcation used in carotid endarterectomy,t he dissection proceeds anteriorly and medial to the internal jugular vein. The facial vein requires division, allowing the jugular vein to be retracted laterally to expose the carotid bifurcation (Fig. 1).The retrojugular approach was originally described to allow dissectionthrough unscarred tissue for re-do surgery or to provide better exposure of the distal internal carotid artery in high lesions. Here, the dissection proceeds behind the internal jugular vein, which is retracted anteriorly and medially to expose the carotid bifurcation. This avoids the facial vein and the small anterior branches of the internal jugular vein at the upper end of the incision (Fig. 2).Recent reports have stimulated ar esurgence of interest in the retrojugular approach, showing it to be safe and possibly faster than the anteromedial approach. 2,3However, concerns have been raised with regard to cranial nerve injury witht he retrojugular approach, 4,5 in particular, whether the accessory nerve may be prone to injury.The aim of this study was to investigate whether the incidence of cranial nerve injuries associated with the retrojugular approach was differentf rom that of the anteromedial approach. Patients and Methods Study designData were obtained from ap rospectively maintained database containing details of 461 carotid endarterectomies performed by or under the supervision of asingle surgeon (CPG) over a1 6-year period and were analysed retrospectively to determine the incidence of cranial nerve injury. PatientsAtotal of 236 (164 males; 72 females; median age, 69 years; range, 43-85 years) primary carotid endarterectomies performed under local anaesthetic using the eversion technique were identified from the database of which 145 were performed via the anteromedial approach and 91 by the retrojugular approach. The choice of approach depended mainly on the date of surgery as the preference of

Meta-analysis of retrojugular versus antejugular approach for carotid endarterectomy

“…1,4,5,[7][8][9] The analysis included 740 CEAs, 333 of which were performed using the retrojugular approach and 407 with the antejugular approach. The reports were published between 2002 and 2009.…”

“…Two studies were randomised controlled trials (RCTs) 5,6 and another three studies were retrospective or prospective observational reports. 1,4,9 A correspondence reporting a brief summary of a single author retrospective experience was included. 8 The…”

“…The retrojugular approach is an alternative technique that was used originally to provide an easier and safer dissection plane through unscarred tissue in 'redo' surgery or to allow better exposure in high carotid lesions. 1 In recent years, there has been a resurgence of interest in the retrojugular approach as an alternative approach to CEA. 1,2 Proponents of this technique assert it to be safe and afford higher exposure of the internal carotid artery, especially in high bifurcations.…”

“…1 In recent years, there has been a resurgence of interest in the retrojugular approach as an alternative approach to CEA. 1,2 Proponents of this technique assert it to be safe and afford higher exposure of the internal carotid artery, especially in high bifurcations. Furthermore, absence of posterior branches of the internal jugular vein and decreased need for mobilisation of the hypoglossal nerve may create shorter operating times.…”

Continuous Vagus Nerve Monitoring during Carotid Endarterectomy

“…VN damage can lead to undesirable consequences, including vocal disturbance, aspiration, and dysphagia. Although VN palsy is a serious complication of CEA, the causes of VN injury are not well understood [3] [4]. In patients undergoing neck surgery, intraoperative neuromonitoring has been advocated as a method of localizing and identifying the recurrent laryngeal nerve (RLN), as well as being used to predict postoperative vocal fold function [5] [6].…”