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Cranial and Cervical Nerve Injuries After Repeat Carotid Endarterectomy

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View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector Cranial and cervical nerve injuries after repeat carotid endarterectomy Ali F. AbuRahma, MD,a and Mark A. Choueiri, MD,b Charleston, WVa Background and Purpose: The incidence of cranial and/or cervical nerve injuries after pri- mary carotid endarterectomy (CEA) ranges from 3% to 48%; however, the clinical out- come of these injuries after repeat CEA has not been thoroughly analyzed in the English- language medical literature. This prospective study analyzes the incidence and outcome of cranial nerve injuries after repeat CEA. Patients and Methods: This study includes 89 consecutive patients who had repeat CEAs. Preoperative and postoperative cranial nerve evaluations were performed, including clin- ical examinations (neurologic) and direct laryngoscopy. Patients with vagal or glos- sopharyngeal nerve injuries also underwent comprehensive speech evaluations, video stroboscopy, fluoroscopy, and methylene blue testing for aspiration. Patients with post- operative cranial nerve injuries were followed up for a long time to assess their recovery. Results: Twenty-five cranial and/or cervical nerve injuries were identified in 19 patients (21%). They included 8 hypoglossal nerves (9%), 11 vagal nerves or branches (12%) (6 recurrent laryngeal nerves [7%], 3 superior laryngeal nerves [3%], and 2 complex vagal nerves (2%]), 3 marginal mandibular nerves (3%), 2 greater auricular nerves (2%), and 1 glossopharyngeal nerve (1%). Twenty-two (88%) of these injuries were transient with a complete healing time ranging from 2 weeks to 28 months (18 of 22 injuries healed with- in 12 months). The remaining three injuries (12%) were permanent (1 recurrent laryn- geal nerve, 1 glossopharyngeal nerve, and 1 complex vagal nerve injury). The recurrent laryngeal nerve injury had a longer healing time than the other cranial nerve injuries. Conclusions: Repeat CEA is associated with a high incidence of cranial and/or cervical nerve injuries, most of which are transient. However, some of these have a long healing time, and a few can be permanent with significant disability. (J Vasc Surg 2000;32:649-54.) With a larger number of patients undergoing and in good-risk patients with asymptomatic high- carotid endarterectomy (CEA) and with the use of grade (> 80%) recurrent stenotic lesions.1-7 In many postoperative carotid duplex scan surveillance, an studies it has been reported that repeat CEA can be increasing number of recurrent carotid artery stenoses performed by vascular surgeons, with morbidity and are being detected.1-7 Some patients with recurrent mortality rates somewhat similar to that of primary carotid stenoses are symptomatic and are referred for CEA.2-4,6,7 The major complication rates examined repeat CEAs. Most authors advocate a repeat CEA in usually involve stroke, myocardial infarction, and patients with severe symptomatic recurrent stenosis death. Cranial nerve injuries are usually considered minor complications. In multiple studies, researchers From the Vascular Sectiona and the Department of Surgery,a,b the have described cranial nerve injuries after primary Robert C. Byrd Health Sciences Center of West Virginia CEA. The incidence of these injuries is highly variable University and the Charleston Area Medical Center. according to the type of study performed (prospective Competition of interest: nil. vs retrospective) and how aggressively the injury is Presented at the Twenty-eighth Annual Symposium on Vascular sought.8-17 In several studies, a 3% to 48% incidence of Surgery of the Society for Clinical Vascular Surgery, Rancho Mirage, Calif, Mar 15-19, 2000. cranial nerve injury after a primary CEA has been 9-17 Reprint requests: Ali F. AbuRahma, MD, 3100 MacCorkle Ave, reported ; however, in most studies the range was SE, Suite 603, Charleston, WV 25304 (e-mail: ali.aburama@ 3% to 23%.16 The incidence of cranial nerve injury camcare.com). after repeat CEA is generally thought to be higher Copyright © 2000 by The Society for Vascular Surgery and The than after primary CEA because of the fibrotic tissue American Association for Vascular Surgery, a Chapter of the 4,6 International Society for Cardiovascular Surgery. reaction obscuring the planes of dissection. 0741-5214/2000/$12.00 + 0 24/6/109751 However, the clinical outcome of these injuries after doi:10.1067/mva.2000.109751 repeat CEA has not been thoroughly analyzed in the 649 JOURNAL OF VASCULAR SURGERY 650 AbuRahma and Choueiri October 2000 English-language medical literature. This prospective test to check for aspiration. These evaluations were study analyzes the incidence and outcome of cranial repeated within 30 days of the initial evaluation. nerve injury after repeat CEA. Patients who had cranial and/or cervical nerve injuries were entered into regular follow-up to assess PATIENTS AND METHODS delayed recovery. The following cranial and/or cervi- This prospective report analyzes the incidence of cal nerve injuries were specifically attended to: the cranial and cervical nerve injuries in 89 consecutive mandibular branch of the facial nerve, the vagal repeat CEAs (84 patients) during a 10-year period nerve and its branches (superior laryngeal nerve and (January 1988–December 1997). Patients were treat- recurrent laryngeal nerve), the glossopharyngeal ed by the vascular surgery service at the Charleston nerve, the hypoglossal nerve, the spinal accessory Area Medical Center, Robert C. Byrd Health Sciences nerve, and the greater auricular nerve. Center of West Virginia University, Charleston, WVa Division. The patients’ original CEA was performed RESULTS with primary closure, except in 5 cases where closure Eighty-four patients underwent 89 consecutive was achieved with a Hemashield patch in 3, a vein repeat CEAs; five patients had bilateral repeat CEAs. patch in 1, and a polytetrafluoroethylene patch in 1. Fifty-three patients were men, and 31 were women All patients had a repeat CEA with cardiovascular with a mean age of 66.5 years (range, 43-79 years). polytetrafluoroethylene patch angioplasty (Goretex, Indications for the repeat CEA included 71 (80%) of Flagstaff, Ariz) while they were under general anes- 89 CEAs for symptomatic recurrent severe carotid thesia with shunting. artery stenosis and 18 CEAs (20%) for asymptomatic All patients underwent preoperative clinical eval- high-grade (> 80%) stenosis, which was established uations before repeat CEA, including indirect by means of duplex scanning with magnetic reso- and/or direct laryngoscopy. All patients underwent nance angiography or arteriography. The incidence preoperative indirect laryngoscopy, whereas 21 of 30-day perioperative strokes was five (5.6%) of 89 patients underwent direct laryngoscopy: 5 who had a CEAs, with no perioperative mortality. prior history of cranial nerve injury, 5 who had bilat- Follow-up ranged from 6 to 126 months. eral CEA, and 11 others who had prior high carotid Twenty-five cranial and/or cervical nerve injuries lesion in the primary CEA or in whom findings were were identified in 19 patients (21%). They included found on indirect laryngoscopy. A speech therapy 8 hypoglossal nerves (9%), 11 vagal nerves or evaluation, an examination by an otolaryngologist, branches (12%) (6 recurrent laryngeal nerves [7%], and a comprehensive neurologic examination were 3 superior laryngeal nerves [3%], and 2 complex performed for five patients with a prior history sug- vagal nerve injuries [2%]), 3 marginal mandibular gestive of an injury to the cranial nerves: 2 with vagal nerves (3%), 2 greater auricular nerves (2%), and 1 nerve injuries, 2 with hypoglossal nerve injuries, and glossopharyngeal nerve (1%). 1 with an injury of the mandibular branch of the Twenty-two (88%) of these injuries were transient facial nerve. All of these patients had a complete with a complete healing time ranging from 2 weeks recovery before the repeat CEA. All patients under- to 28 months (18 of 22 healed within 12 months). went a postoperative comprehensive clinical (neuro- The remaining three injuries (12%) were permanent logic) examination and a laryngoscopic examination (1 recurrent laryngeal nerve, 1 glossopharyngeal (indirect and/or direct) before discharge. Again, all nerve, and 1 complex vagal nerve injury). patients underwent postoperative indirect laryn- When the three patients with permanent nerve goscopy, whereas 47 patients underwent direct laryn- injury were excluded, the average healing time (as goscopy. These patients included those who had pre- determined by clinical observation and laryngoscopy operative direct laryngoscopy and patients with a examination) for these nerves were as follows: clinical picture suspicious of cranial nerve injury (eg, hypoglossal nerve, 3.5 months; great auricular voice changes, difficulty in swallowing, evidence of nerve, 5 months; marginal mandibular nerve, 6.2 other cranial nerve injury, indirect laryngoscopy find- months; vagal nerve, 6.8 months; superior laryngeal ings). Also, patients with clinical evidence of postop- nerve, 8.5 months; and recurrent laryngeal nerve, erative cranial nerve injury were thoroughly evaluat- 13.5 months. The recurrent laryngeal nerve injury ed by a speech therapist and an otolaryngologist. had a longer healing time than the other cranial Patients with a vagal nerve injury or glossopharyn- nerve injuries. geal nerve injury also underwent a video stro- Fifteen patients in our series experienced postop- boscopy, a video fluoroscopy,
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