Is Clinical Examination an Adequate Predictor of Respiratory Dysfunction After Bilateral Carotid Endarterectomy?

Abstract

One of the most feared complications in performing bilateral carotid endarterectomies on patients with bilateral high grade stenosis is vocal cord paralysis with resultant respiratory dysfunction. This has led most surgeons to perform staged carotid endarterectomies separated by 4 to 6 weeks. The purpose of this study is to evaluate respiratory risks postoperatively in patients who have undergone bilateral carotid endarterectomies during the same admission with clinical examination to evaluate vocal cord function. From January 1993 to January 1998, a total of 512 bilateral carotid endarterectomies were performed in 256 patients during a single admission. Operative indications included asymptomatic carotid stenosis 334 (65%), transient ischemic attacks (TIAs) 71 (14%), amaurosis fugax 34 (6.6%), and 33 (6.5%) previous stroke. Data were collected prospectively and included patient demographics, indications for surgery, and operative complications. Patients were evaluated following initial carotid endarterectomy by physical examination. Those patients with hoarseness were then examined by direct laryngoscopy to evaluate the presence of vocal cord paralysis. If no contraindications were found on physical examination, patients underwent contralateral carotid endarterectomy within 48 hours of the initial procedure. Operative mortality rate was 1.6% (four patients). There was one permanent neurologic deficit and one cranial nerve injury after second carotid endarterectomy (0.3%). Six patients had contralateral surgery delayed secondary to hoarseness (2.3%), four with vocal cord dysfunction, and 10 (3.9%) had transient neurologic deficits that improved by the time of their discharge from the hospital. No patient in this study period had respiratory collapse or was compromised after bilateral carotid endarterectomy during the same admission. Bilateral carotid endarterectomy can be performed safely with acceptable results during one hospital admission. There does not appear to be an increased incidence of upper respiratory dysfunction after bilateral carotid endarterectomy that is performed during the same hospital admission. Clinical examination appears to be adequate in predicting respiratory and vocal cord dysfunction postoperatively.