Ipsilateral Carotid Bypass Outcomes in Hostile Neck Anatomy.

Abstract

OBJECTIVE\nTo determine differences in outcomes among patients undergoing ipsilateral carotid bypass with hostile or normal neck anatomy.\n\n\nMETHODS\nSingle-center retrospective review of all ipsilateral extra-cranial carotid bypasses performed between 1998 and 2018.\n\n\nRESULTS\nForty-eight patients underwent ipsilateral carotid bypass from the common carotid artery to either the internal carotid artery or carotid bifurcation during the study period. Seven patients were excluded due to either lack of follow-up or missing data. Indication for intervention included infected patches, aneurysmal degeneration, symptomatic and asymptomatic stenosis/restenosis, carotid body tumors, neck malignancy, and trauma. In 25 procedures (61%) there was hostile neck anatomy defined as a prior history of external beam neck irradiation or neck surgery. Among this group, 12 pectoralis muscle flaps were performed for reconstructive coverage. Conduits included polytetrafluorethylene (n=21), great saphenous vein (n=9), superficial femoral artery (SFA) (n=7) and arterial homograft (n=4). All SFA conduits were used in the hostile neck group (p = 0.03). Overall mean time of follow-up was 22 months with all bypasses remaining patent with no significant clinical stenosis. The 30-day ipsilateral stroke and MI rates were 4.88% each, all within the hostile neck group, with no 30-day mortalities for the entire cohort. One-third of the muscle flaps were performed in the setting of infected patches (p = 0.02) with no significant differences in perioperative outcomes with use. Overall median hospital length of stay was significantly increased in patients receiving muscle flap coverage (3.0 vs 7.0 days, p = 0.04).\n\n\nCONCLUSION\nIn patients with complex carotid pathology, ipsilateral carotid bypass is an effective solution for carotid reconstruction. Different conduits should be used depending on the indication. Muscle flap coverage should be considered in hostile settings when primary wound closure is not feasible.