title: Short longitudinal versus transverse skin incision for carotid endarterectomy: impact on cranial and cervical nerve injuries and esthetic outcome.
abstract: OBJECTIVE
  Nerve injuries, wound complications and especially poor cosmetic results still have an important impact on the carotid endarterectomy (CEA) morbidity. Introduction of the mini skin incision in clinical practice seems to be safe with reduction in postoperative pain and superficial and cranial nerves lesions, and better aesthetics outcomes. The objective of this retrospective study was to compare the results between the short longitudinal with the short transverse cervical incision and to evaluate their impact on cranial and cervical nerves and aesthetic outcomes.
  
  
  METHODS
  From January 2007 to December 2009 266 patients underwent 300 consecutive primary CEA procedures. Two-hundred nineteen patients were submitted to short longitudinal cervical incision (group A), in eighty one a short transverse cervical skin incision (group B) was performed. The average of skin incision was about 4-5.5 cm. In all cases a preoperative CEA duplex ultrasounds (US) assisted skin marking was carried out. All patients were submitted to the general anesthesia with Remifentanyl conserved consciousness. Routinely synthetic patch and selective policy intraluminal shunts were used. Incisions were extended when shunts were required or in case of high carotid bifurcation. Preoperative and postoperative cranial nerves evaluation was always performed and a questionnaire about the satisfaction of the aesthetic outcome was proposed to all patients to the discharge and six months follow-up. Stroke/TIA, death, wound complications, cranial and cervical nerves injuries and restenosis rate were reported and analyzed through statistical analysis (χ2 and Student's t test).
  
  
  RESULTS
  The 30 days mortality was 0.3% (1/300). The TIA rate was 0.91% in group A and 1.2 % in group B (P>0.9). Wound complications were 1.8% and 1.2 % respectively (P>0.1). No statistically differences were reported in the incidence of cranial and cervical nerves injuries between the two groups (P>0.9). No difference in restenosis rate was detected (P>0.9). In case of lengthening of the incision for high internal carotid (ICA) stenosis and especially to the need of shunt deployment, the longitudinal approach showed unequivocally to be easier and safer.
  
  
  CONCLUSIONS
  No differences were achieved between short longitudinal and transverse incision in term of stroke, wound complications or nerves impairment. A good cosmetic outcome was gained in both groups. The Duplex US skin markings pre-CEA permitted localization and limits of the plaque with appropriate short incision. A longitudinal cervical approach is to prefer as can lead to an easier proximal and distal lengthening in cases of atherosclerotic extension of the plaque and shunt deployment.
authors: Vascular and Endovascular Surgery Unit, ASL RM-F "San Paolo" Hospital Civitavecchia, Rome, Italy. gmarcroma@alice.it
authors: G
authors: G
authors: Marcucci
authors: R
authors: R
authors: Antonelli
authors: R
authors: R
authors: Gabrielli
authors: F
authors: F
authors: Accrocca
authors: A G
authors: AG
authors: Giordano
authors: A
authors: A
authors: Siani
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002340:Carotid Artery Diseases / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D002572:Cervical Plexus / Q000293:injuries*; D016009:Chi-Square Distribution; D002921:Cicatrix / Q000209:etiology*; D020209:Cranial Nerve Injuries / Q000209:etiology*; D062109:Dermatologic Surgical Procedures; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D005260:Female; D006801:Humans; D002546:Ischemic Attack, Transient / Q000209:etiology; D007558:Italy; D008297:Male; D008875:Middle Aged; D009333:Neck; D009460:Neurologic Examination; D017060:Patient Satisfaction; D012008:Recurrence; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000209:etiology; D011795:Surveys and Questionnaires; D013997:Time Factors; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex