The surgical management of carotid artery stenosis in patients with previous neck irradiation

BACKGROUND: A history of therapeutic irradiation to the neck complicates the management of carotid artery occlusive disease, Serious surgical concerns are raised regarding alternative incisions, difficult dissections, and adequate wound closure. Pathology may be typical atherosclerotic occlusive disease or radiation-induced arteritis, In order to establish guidelines for the treatment of these patients, we have reviewed our operative experience. PATIENTS AND METHODS: A review of our operative experience over the past 15 years revealed 10 patients with a history of prior irradiation to the neck who underwent 14 carotid operations. RESULTS: The indications for radiation included laryngeal carcinoma and lymphoma, Five patients had undergone previous radical neck dissections, and four patients had permanent tracheostomies. The surgical indications were asymptomatic high-grade stenosis in 7 cases, transient ischemic attack in 4 cases, stroke in 2 cases, and a pseudoaneurysm in 1 case, Conventional carotid endarterectomy with patch angioplasty was used in 10 of the 14 operations, In the remaining four operations, saphenous vein interposition grafting was utilized to replace the diseased segment of carotid artery secondary to a panarteritis, Wound closure required dermal grafting in two of five cases where surgery was performed ipsilateral to a prior radical neck dissection, One perioperative cerebral infarction occurred; there were no other neurologic or non-neurologic complications, All patients are doing well in one- to five-year follow-up, with serial postoperative duplex scans demonstrating no signs of recurrent stenosis. CONCLUSIONS: Patients with a history of irradiation to the neck should be screened for the presence of carotid disease. Carotid occlusive disease should be treated surgically in these patients with the usual indications. Intraoperative surgical management is similar to that of non-irradiated patients. Concerns about difficulty in achieving an adequate endarterectomy plane and about problems with wound closure have generally been unfounded.