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Society For Clinical Vascular Surgery

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Mini-incision CEA can be performed safely, even with the use of a shunt and in obese patients, without an increase in complication rates: Time to bring carotid surgery into the minimally invasive era
Michele N. Richard, MD, Ian Sclieder, DO, Alexander Ostapenko, MD, Shawn Liechty, MD, Maksim Boguslavskiy, DO, Maria Barreras, BS, Soundarapandian Vijayakumar, PhD, Shiquan He, MS, Joann Petrini, PhD MPH, Alan Dietzek, MD FACS.
Danbury Hospital, Danbury, CT, USA.

OBJECTIVES - Carotid endarterectomy (CEA) is commonly performed through large incisions (8-10cm or greater), which often results in postoperative pain and cosmetic dissatisfaction. Previously, this was justified to provide good exposure and minimize complications. Mini-incision CEA (MI-CEA), <6cm, can provide adequate exposure, with minimal postoperative pain and improved cosmetic results. Many vascular surgeons, however, remain uncomfortable with either the perceived technical challenges of a small incision and/or its safety, particularly with shunting. At our teaching community hospital, we compared our postoperative outcomes between standard incision (SI) and MI-CEA to determine if these concerns are justified.
METHODS - Retrospective chart review was performed on all CEAs between 2010-2013. Patients were divided into 2 groups: SI-CEA (>6cm) and MI-CEA (<6cm). No patient in the SI-CEA group was initially excluded or converted from an initial attempt at MI-CEA. Primary outcome was postoperative complications, including nerve injuries, stroke, and reoperation. BMI was evaluated as a possible contributing factor to complications in patients with potentially larger necks. Data analysis performed using Fisherís Exact test, Pearsonís chi-square, Wilcoxon rank-sum, t-test and Logistic regression.
RESULTS - 256 patients were included: 113 SI-CEA, and 143 MI-CEA. Median age was 73 years (range 35,91) for SI-CEA and 76 years (range 55,93) for MI-CEA (p=0.02). Median incision length for MI-CEA was 4.0cm (range 2.8,5.5). Both groups had similar median BMI: MI-CEA 27 (range 17,48) and SI-CEA 26 (range 20,48) (p=0.138). Despite significant variations in baseline characteristics of diabetes, age, prior stroke, pre-existing neurological deficit, use of shunt, and type of procedure (standard vs eversion), none had significant marginal association with primary outcome. Thus, they were excluded from multivariate analysis, which showed no significant association (p=0.442) between postoperative complications and incision length (table).
CONCLUSIONS - These results show that MI-CEA is a safe operation, with no increase in postoperative complications, especially nerve injury, a feared outcome of CEA with limited exposure. Also, patient habitus and shunt use did not alter complication rates. MI-CEA can be easily learned by all vascular surgeons and, we believe, will result in safe outcomes and greater patient satisfaction, particularly relevant in the present minimally invasive era.

ComplicationsSI-CEA (n=113)MI-CEA (n=143)P-value
Overall Postoperative Complications26 (23.01%)20 (13.99%)0.089
Cranial Nerve Injuries, All Temporary5 (4.42%)5 (3.50%)0.754
Stroke3 (2.65%)1 (0.70%)0.325
Myocardial Infarction3 (2.65%)1 (0.70%)0.325
Reoperation2 (1.77%)2 (1.40%)1.000

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