Acta chir belg, 2006, 106, 397-399
Does Retrojugular Route for Carotid Endarterectomy Increase the Risk of
Internal Jugular Vein Thrombosis ?
V. Scavée*, S. Theys**, J. C. Schoevaerdts**
Department of Thoracic and Vascular Surgery*, Saint-Pierre Clinic, Ottignies and Department of Vascular Surgery**,
University Clinic of Mont-Godinne (UCL), Yvoir, Belgium.
Key words. Internal jugular vein thrombosis ; retrojugular route ; carotid endarterectomy.
Abstract. Two different approaches are available to perform carotid endarterectomy : the traditional antejugular or the
retrojugular route. With retrojugular route, direct access to the carotid arteries necessitates median retraction and often
collapse of the internal jugular vein (IJV). Therefore, we have prospectively evaluated the potential incidence of IJV
thrombosis.
Introduction
Recent large prospective randomized trials previously
demonstrated the superiority of carotid endarterectomy
(CEA) over medical management to reduce the incidence of strokes among patients, selected both symptomatic and asymptomatic, with significant extracranial
internal carotid artery stenosis (1-4).
Whatever the surgical technique used, carotid arteries
dissection is either performed by a traditional antejugular approach or by a retrojugular route (5-6). With the
retrojugular route, the internal jugular vein (IJV) is
retracted medially and often collapse, by two umbilical
tapes (Fig. 1), to allow direct access to the internal
carotid artery (5-6).
Then, the purpose of our study was to evaluate the
potential occurrence of IJV thrombosis following retrojugular route for CEA.
Fig. 1
With retrojugular route, direct access to the carotid arteries
(ICA) necessitates median retraction and often collapse of the
internal jugular vein (IJV).
Material and Methods
Patients demographics and risk factors
Between September 2003 and November 2003,
20 patients underwent primary CEA following a standard uniform technique. There were 10 men (50%) and
10 women with a mean age of 71.8 years (range, from
44 to 82). Pertinent atherosclerotic risk factors and indications for CEA are listed in Table 1.
Preoperative data
The degree of internal carotid stenosis and the anatomical features were evaluated by both ultrasonography and
MRA. The mean internal carotid artery degree of stenosis was 85 ± 6.3%. Preoperative duplex ultrasound scans
were performed the day before procedure, including
specific evaluation to bilateral IJV. Doppler with colour
flow provided information about venous compression,
patency and direction of flow (7)
Surgical technique
All patients were operated under general endotracheal
anaesthesia with full cardiovascular monitoring. The
CEA procedures were performed through a longitudinal
neck incision with exposure of the extracranial carotid
artery by a retrojugular route, as previously described (5-6). With retrojugular route, direct access to the
carotid arteries necessitated median retraction and often
collapse of the IJV (Fig. 1). Systemic heparin was
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V. Scavée et al.
Table 1
Risk factors and indications for surgery in 20 patients who
underwent CEA through retrojugular route
Variables
N
%
15
13
9
9
8
8
75
65
45
45
40
40
Risk factors
Hypertension
Smoking history
Pulmonary disease
Diabetes mellitus
Coronary artery disease
Peripheral artery disease
CEA indications
Asymptomatic
Transient ischaemic attack
Stroke
12
5
3
60
25
15
administrated (30 U/Kg body weight) prior to carotid
clamping. Routine temporary shunt (Javid™, C.R.
Bard®, Inc., USA) was used and the arteriotomy was
closed by autologous ankle venous patching. Mean
operative time was 92 minutes (range, from 75 to 104).
Heparin administered was not reversed at the end of the
procedure. The postoperative care was delivered in the
intensive care unit for 24 h and 160 mg aspirin daily was
prescribed after surgical procedure.
Follow-up
Postoperative clinical, neurological evaluation and all
complications were assessed. Postoperative duplex
ultrasound scans were performed before hospital discharge, at 3 and 6 months, with specific evaluation of the
jugular veins. Only qualitative venous Doppler features
were assessed (7).
Results
During the 30-day postoperative period, there was no
neurological event or death. One patient (5%) developed
recurrent laryngeal nerve dysfunction without recovery
after 6 months. No wound infection or haematoma formation required surgical evacuation.
The mean follow-up was 12 months and no signs or
symptoms of IJV occlusion were recorded during the
postoperative course. At 3, 6 and 12 months after the
procedure, all carotid arteries evaluated by duplex
remained patent, without thrombosis or recurrent stenosis. In addition, there was no dilation or aneurismal
degeneration of the patch.
With regards to preoperative venous imaging, both
IJV of 20 patients were patent and no hypoplasia, agenesis or thrombosis vein were observed. On the first postoperative Doppler, two patients presented turbulent flow
in IJV. However, all IJV were easily compressible, with
thin walls and spontaneous flow toward the heart. The
blood flow was normally modulated with cardiac, respiratory cycles and valsalva manoeuvre. No defect of
venous filling and thrombosis was reported. During
further Doppler (3, 6 and 12 months), IJV remained
patent without direct or indirect signs of thrombosis or
stenosis.
Discussion
Retrojugular approach for carotid endarterectomy presented several potential advantages (5-6).
First, the exposition of the carotid artery is performed
without division of any major branch of the IJV and
lymphatic tissues are preserved. Furthermore, the simplicity of the anatomical dissection significantly reduces
the operating time. Finally, recent trials reported no cranial nerve dysfunction (5-6).
However, with retrojugular approach, direct access to
the carotid arteries necessitates median retraction and
often collapse of the internal jugular vein, especially in
the higher cervical segment. Although the operative time
in our study is relatively long, mainly due to routine
temporary shunt use and saphenous vein patch angioplasty, we did not find any direct or indirect evidence of
IJV stenosis or thrombosis. Only two patients presented
turbulent flow without neither clinical consequence nor
thrombosis on further Doppler evaluation.
With respect to the quantitative Doppler parameters,
PRIM et al. (8) reported a high disparity of area, expiratory and jugular flow speed between right and left IJV
for patients with head and neck cancer. But, no statistically significant differences were found between sides.
The venous flow is normally affected by both the respiratory and cardiac cycles (7), and thus prevents any
objective conclusions about potential preoperative and
postoperative measurements. Consequently, in our
study, in addition to the qualitative parameters, we only
registered as quantitative Doppler features the presence
and the direction of venous flow.
In order to confirm the absence of IJV thrombosis
after CEA through retrojugular route, greater clinical
experience and long-term follow-up are required.
References
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Retro Jugular Carotid Exposure
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V. Scavée
Department of Thoracic and Vascular Surgery
Saint-Pierre Clinic
Avenue Reine Fabiola
B-1340 Ottignies, Belgium
Tel.
: +32 10 43 72 35
E-mail : vincent.scavee@skynet.be