title: Mini skin incision for carotid endarterectomy (CEA): a new and safe alternative to the standard approach.
abstract: OBJECTIVE
  Patients requiring surgery are naturally attracted to shorter incisions because they tend to cause less pain and are esthetically more appeasing. To substantially shorten the length of standard skin incisions (4 to 7 inches) for carotid endarterectomy (CEA), we used preoperative duplex scanning to outline the carotid bifurcation as well as to determine the extent of disease in both the internal and common carotid arteries.
  
  
  METHODS
  During the last 21 months, 265 consecutive primary CEAs were performed in 253 patients (mean age 72 +/- 10 years) at a single institution. Of these, 142 were men (56%). Hypertension, coronary artery disease, diabetes mellitus, smoking, and chronic renal failure were present in 81%, 44%, 43%, 28%, and 19% of the patients, respectively. Neurologically asymptomatic patients accounted for 71% of the cases. All patients received general anesthesia. Duplex-assisted skin markings of the diseased carotid artery were performed after proper patient positioning on the operating table. Synthetic patches were routinely used, and intraluminal shunts were deemed necessary by low stump pressures in 64 cases (24%). Completion duplex scanning was performed in all cases.
  
  
  RESULTS
  The length of the longitudinal skin incision varied from 0.8 to 3.5 inches (average 1.4 +/- 0.5 inches). It was < or = 1 inch in 56 cases (21%), 1.1 to 1.5 inches in 110 (42%), 1.6 to 2 inches in 85 (32%), and 2.1 to 3.5 inches in the remaining 14 cases (5%). Intraluminal shunts were required in 9 (16%), 18 (16%), 29 (34%), and 8 (57%) of the cases, respectively. Incisions were longer in cases requiring an indwelling shunt (1.6 +/- 0.6 inches vs 1.4 +/- 0.4 inches) (P < .0001). The average patch length was 1.3 +/- 0.3 inches (range, 0.7 to 2.6 inches). The skin incision averaged 1.54 +/- 0.45 inches for the first 133 cases and 1.35 +/- 0.45 inches for the remaining 132 cases (P < .0001). Technical defects occurred in 10 cases (3.8%). The overall incidence of ipsilateral stroke and death was 1.9% and 0%. There were no technical defects or strokes in patients with the shortest incisions (< or = 1 inch). Overall, there were three transitory peripheral nerve injuries (1.1%). A comparative analysis with 265 consecutive CEAs performed immediately before this series without duplex-assisted skin markings revealed no significant differences in age (71 +/- 11 years), incidence of neurologically symptomatic patients (26%), sex (60% men), shunt use (24%), and major technical defects (3%). Also, postoperative transitory peripheral nerve injury (0.8%), stroke (0%), and death (0%) were not significantly different from the duplex-assisted group. It is of interest to note that none of the former cases was performed with a skin incision < or = 2 inches.
  
  
  CONCLUSIONS
  Most CEAs (95%) can safely be performed with < or = 2-inch skin incisions. Pre-CEA duplex-assisted skin marking is a novel approach that confirms the side of the operation, localizes the disease, and minimizes the magnitude of the operation via shorter, more esthetically pleasing incisions.
authors.affiliation: Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY, USA. eascher@maimonidesmed.org
authors.forename: Enrico
authors.initials: E
authors.lastname: Ascher
authors.forename: Anil
authors.initials: A
authors.lastname: Hingorani
authors.forename: Natalie
authors.initials: N
authors.lastname: Marks
authors.forename: Richard W
authors.initials: RW
authors.lastname: Schutzer
authors.forename: Manikyam
authors.initials: M
authors.lastname: Mutyala
authors.forename: Suresh
authors.initials: S
authors.lastname: Nahata
authors.forename: William
authors.initials: W
authors.lastname: Yorkovich
authors.forename: Theresa
authors.initials: T
authors.lastname: Jacob
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017536:Carotid Artery, Common; D002343:Carotid Artery, Internal; D016893:Carotid Stenosis / Q000000981:diagnostic imaging / Q000601:surgery*; D062109:Dermatologic Surgical Procedures; D016894:Endarterectomy, Carotid / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011300:Preoperative Care / Q000379:methods*; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex