Meta-analysis of retrojugular versus antejugular approach for carotid endarterectomy

Abstract

INTRODUCTIONThe 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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“…However, the retrojugular approach was associated with significantly higher rates of recurrent laryngeal nerve palsy (8.1% vs. 2.2%), with no evidence of reduced rates of hypoglossal nerve injury (1.3% vs. 1.3%). 279 2.4.1. 7.…”

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“…As an alternative, a retro-jugular approach to the carotid bifurcation reduces this risk and has a shorter operative time, but it is associated with the risk of vagal or accessory nerve injury. Several studies have investigated novel approaches and compared the incidence of neurologic complications to that of the conventional anteromedial jugular approach [ 17 , 18 ]. Antoniou et al [ 17 ] conducted a meta-analysis of retro-jugular versus ante-jugular approaches for CEA and showed a higher incidence of laryngeal nerve damage in the retro-jugular approach than in the ante-jugular approach (8.1% and 2.2%, respectively; p=0.004), and no statistically significant difference in the incidence of hypoglossal or accessory nerve damage, persisting nerve damage, stroke, or death.…”