Risk factors for Cranial Nerve Injury after Carotid Endarterectomy in NSQIP CEA-targeted Database
Kyla M Bennett, John E Scarborough, Cynthia K Shortell
Duke University Medical Center, Durham, NC
Background: Although numerous studies have described the incidence of postoperative cranial nerve injury (CNI) after carotid endarterectomy (CEA), there have been very few attempts to identify risk factors for this complication.
Methods: The 2012 CEA-targeted ACS NSQIP database was used to determine the incidence of CNI after CEA. A patient was noted to have a postoperative CNI if their in-hospital or post-discharge (up to 30 days) medical record contained mention of such injury, or of symptoms consistent with such injury. Thus, those CNIs captured by this database are likely to represent clinically relevant injuries. Multivariate logistic regression analysis was performed to identify independent predictors of CNI after CEA, using a comprehensive array of patient-, disease- and procedure-related factors (including prior ipsilateral carotid surgery and other high-risk anatomic risk factors) as potential predictor variables.
Results: Of the 4,013 patients who underwent CEA and were included in our analysis, 87 (2.2%) were noted to have sustained CNI in the first 30 postoperative days. Independent predictors of this complication included age ≥ 80 years [reference group < 70 years; AOR for CNI 1.74 (95% CI 1.00,3.03), p = 0.05], preoperative bleeding disorder (including patients in whom preoperative anticoagulation was not stopped or reversed; AOR 1.66 (95% 1.03,2.68), p = 0.04], duration of operation [AOR 1.15 for each 30 minutes beyond operative time of 90 minutes (95% CI 1.06,1.25), p = 0.001], and need for reoperation [AOR 2.65 (95% CI 1.03,6.80), p = 0.04].
Conclusions: Our study demonstrates clinically evident CNI to be a relatively uncommon event after CEA at institutions that participate in the CEA-targeted ACS NSQIP program. Anatomic high-risk factors (including prior neck irradiation or ipsilateral carotid surgery) were not significantly associated with an increased incidence of CNI in our study, although such factors are typically cited as relative contraindications to CEA (instead of carotid stenting). The findings of our study do suggest that patients who require prolonged operation (for hemostasis or other reasons) may benefit if possible from intermittent release of intraoperative retraction in order to prevent temporary cranial nerve palsy, and that surgeons should exercise particular caution in patients who require early reoperation after CEA.
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