no significant differences in the perioperative (30 day) rates for mortality, stroke, or transient ischemic attack (TIA) when comparing redo CEA with TF-CAS performed for restenosis. Patients undergoing redo CEA had significantly increased incidence of cranial nerve injury compared with those undergoing CAS, but most patients recovered within three months. However, the risk of stenosis after intervention for restenosis was greater in TF-CAS patients compared with redo CEA patients. In a later review of patients who underwent intervention for restenosis (479 CEA, 653 transfemoral CAS), the primary endpoint of stroke and death for TF-CAS was also similar (2.7 and 2.3 percent) [93]. In reviews of the Vascular Quality Initiative (VQI) since the introduction of TCAR, TCAR for restenosis following CEA is associated with decreased risk of perioperative ischemic events compared with TF-CAS or redo CEA [65,94]. The later of these reviews identified 4425 patients operated on between September 2016 and April 2020 and who underwent redo CEA (21.8 percent), TF-CAS (40.4 percent), or TCAR (37.9 percent) after ipsilateral CEA [65]. Compared with redo CEA, TCAR was associated with lower risk of stroke/TIA (1.31 versus 3.53 percent) and stroke (1.02 versus 2.49 percent), which remained significant after adjustment for other risk factors. Mortality was not significantly different between the groups (0.54 percent and 0.42 percent, respectively). TCAR was also associated with lower risk of stroke/TIA compared with TF- CAS (1.3 versus 3.1 percent). Other differences between TCAR and TF-CAS were not significant after adjustment. Data regarding the risk for restenosis after TCAR either performed as the index operation or for restenosis following CEA are not available. However, although the technique for placement of the stent differs for TCAR compared with TF-CAS, once the stent is in place, any long-term problems seen with TF-CAS may also occur with TCAR. https://www.uptodate.com/contents/complications-of-carotid-endarterectomy/print 12/26 7/5/23, 11:38 AM Complications of carotid endarterectomy - UpToDate SOCIETY GUIDELINE LINKS Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Occlusive carotid, aortic, renal, mesenteric, and peripheral atherosclerotic disease".) SUMMARY AND RECOMMENDATIONS The accepted indications for carotid endarterectomy (CEA) balance the long-term benefit of stroke reduction with the risk of perioperative complications, which can be related to the technique of performing carotid endarterectomy or to underlying cardiovascular disease and other comorbid conditions. Postoperative complications diminish the overall long-term benefit of performing the procedure. (See 'Introduction' above and 'General considerations' above.) Myocardial infarction occurs at a low rate (0 to 2 percent) following CEA. Stroke rates range from less than 0.25 to more than 3 percent depending upon the indication for CEA (asymptomatic, symptomatic) and other factors, including the experience of the surgeon. Although neurologic changes following CEA can be related to physiologic changes, or intracerebral etiologies, technical problems related to the carotid surgery must be identified and corrected. (See 'Myocardial infarction' above and 'Perioperative stroke' above.) Cerebral hyperperfusion syndrome is an uncommon sequela of CEA. Risk factors include perioperative hypertension, high-grade carotid stenosis, and possibly recent cerebral infarction. The mechanism of hyperperfusion is related to loss of autoregulation that impairs the ability of the brain to accommodate to restored blood flow. Clinical manifestations may include headache, seizures, and stroke. The best management is prevention with strict control of postoperative hypertension through the first weeks postprocedure. (See 'Hyperperfusion syndrome' above.) Cervical hematoma can become life-threatening due to airway compromise. The main risk factor for cervical hematoma is perioperative antithrombotic therapy. When a significant neck hematoma develops in the postoperative period, immediate return to the operating room and re-exploration of the neck wound is mandatory. (See 'Cervical hematoma' above.) Nerve injuries can occur following CEA. The majority of cranial nerve injuries resolve after surgery, and the risk of permanent cranial nerve deficit is low. The most common nerves https://www.uptodate.com/contents/complications-of-carotid-endarterectomy/print 13/26 7/5/23, 11:38 AM Complications of carotid endarterectomy - UpToDate injured include the hypoglossal nerve, recurrent laryngeal (vagus nerve), and marginal mandibular branch of facial nerve. Risk factors for nerve injury include prolonged procedure duration, urgent procedure, the need for re-exploration (immediate or delayed), and perioperative stroke. (See 'Nerve injury' above.) Wound infection rarely occurs following CEA, and when it occurs, most are superficial and self-limited, resolving with antibiotic therapy. Deep wound infections involving a carotid patch can present early or in a delayed fashion months after the procedure. Initial management includes wound drainage and empiric antibiotic therapy until definitive culture and sensitivity results are available. (See 'Infection' above.) Carotid restenosis after CEA occurs in 2 to 10 percent of patients at five years. Early restenosis CEA is frequently a highly cellular intimal hyperplasia and minimally ulcerated with a low likelihood of symptomatic embolization, whereas late restenosis occurring more than two to three years after CEA is due to progression of atherosclerotic disease. Risk factors for restenosis include age <65, smoking, female sex, and possibly primary closure of the carotid artery at the time of CEA. Lipid-lowering drugs may be protective for both early and late restenosis. Treatment options for significant restenosis include repeat CEA, transfemoral carotid artery stenting, or transcarotid artery stenting. (See 'Carotid restenosis' above.) ACKNOWLEDGMENTS The UpToDate editorial staff acknowledges Emile R Mohler, III, MD (deceased), who contributed to an earlier version of this topic review. The editorial staff at UpToDate also acknowledges Ronald M Fairman, MD, who contributed to an earlier version of this topic review. Use of UpToDate is subject to the Terms of Use. REFERENCES 1. Moore WS, Barnett HJ, Beebe HG, et al. Guidelines for carotid endarterectomy. A multidisciplinary consensus statement from the Ad Hoc Committee, American Heart Association. Circulation 1995; 91:566. 2. Biller J, Feinberg WM, Castaldo JE, et al. Guidelines for carotid endarterectomy: a statement for healthcare professionals from a Special Writing Group of the Stroke Council, American https://www.uptodate.com/contents/complications-of-carotid-endarterectomy/print 14/26 7/5/23, 11:38 AM Complications of carotid endarterectomy - UpToDate Heart Association. Circulation 1998; 97:501. 3. International Carotid Stenting Study investigators, Ederle J, Dobson J, et al. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet 2010; 375:985. 4. Brott TG, Hobson RW 2nd, Howard G, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 2010; 363:11. 5. Silver FL, Mackey A, Clark WM, et al. Safety of stenting and endarterectomy by symptomatic status in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). Stroke 2011; 42:675. 6. Wu TY, Anderson NE, Barber PA. Neurological complications of carotid revascularisation. J Neurol Neurosurg Psychiatry 2012; 83:543. 7. Hill MD, Brooks W, Mackey A, et al. Stroke after carotid stenting and endarterectomy in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Circulation 2012; 126:3054. 8. Saedon M, Singer DR, Pang R, et al. Registry report on kinetics of rescue antiplatelet treatment to abolish cerebral microemboli after carotid endarterectomy. Stroke 2013; 44:230. 9. Heyer EJ, Mergeche JL, Bruce SS, et al. Statins reduce neurologic injury in asymptomatic carotid endarterectomy patients. Stroke 2013; 44:1150. 10. Faggioli G, Pini R, Mauro R, et al. Perioperative outcome of carotid endarterectomy according to type and timing of neurologic symptoms and computed tomography findings. Ann Vasc Surg 2013; 27:874. 11. Sfyroeras GS, Bessias N, Moulakakis KG, et al. New cerebral ischemic lesions after carotid endarterectomy. Ann Vasc Surg 2013; 27:883. 12. Barbetta I, Carmo M, Mercandalli G, et al. Outcomes of urgent carotid endarterectomy for stable and unstable acute neurologic deficits. J Vasc Surg 2014; 59:440. 13. Goldberg JB, Goodney PP, Kumbhani SR, et al. Brain injury after carotid revascularization: outcomes, mechanisms, and opportunities for improvement. Ann Vasc Surg 2011; 25:270. 14. Chamorro A, Vila N, Saiz A, et al. Early anticoagulation after large cerebral embolic infarction: a safety study. Neurology 1995; 45:861. 15. Anzuini A, Briguori C, Roubin GS, et al. Emergency stenting to treat neurological complications occurring after carotid endarterectomy. J Am Coll Cardiol 2001; 37:2074. https://www.uptodate.com/contents/complications-of-carotid-endarterectomy/print 15/26 7/5/23, 11:38 AM Complications of carotid endarterectomy - UpToDate 16. National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333:1581. 17. Liu ZJ, Fu WG, Guo ZY, et al. Updated systematic review and meta-analysis of randomized clinical trials comparing carotid artery stenting and carotid endarterectomy in the treatment of carotid stenosis. Ann Vasc Surg 2012; 26:576. 18. Liu Z, Shi Z, Wang Y, et al. Carotid artery stenting versus carotid endarterectomy: systematic review and meta-analysis. World J Surg 2009; 33:586. 19. Blackshear JL, Cutlip DE, Roubin GS, et al. Myocardial infarction after carotid stenting and endarterectomy: results from the carotid revascularization endarterectomy versus stenting trial. Circulation 2011; 123:2571. 20. Boulanger M, Cameli re L, Felgueiras R, et al. Periprocedural Myocardial Infarction After Carotid Endarterectomy and Stenting: Systematic Review and Meta-Analysis. Stroke 2015; 46:2843. 21. Jones MR, Howard G, Roubin GS, et al. Periprocedural Stroke and Myocardial Infarction as Risks for Long-Term Mortality in CREST. Circ Cardiovasc Qual Outcomes 2018; 11:e004663. 22. Youkey JR, Clagett GP, Jaffin JH, et al. Focal motor seizures complicating carotid endarterectomy. Arch Surg 1984; 119:1080. 23. Reigel MM, Hollier LH, Sundt TM Jr, et al. Cerebral hyperperfusion syndrome: a cause of neurologic dysfunction after carotid endarterectomy. J Vasc Surg 1987; 5:628. 24. Naylor AR, Ruckley CV. The post-carotid endarterectomy hyperperfusion syndrome. Eur J Vasc Endovasc Surg 1995; 9:365. 25. Coutts SB, Hill MD, Hu WY. Hyperperfusion syndrome: toward a stricter definition. Neurosurgery 2003; 53:1053. 26. Kablak-Ziembicka A, Przewlocki T, Pieniazek P, et al. Predictors of cerebral reperfusion injury after carotid stenting: the role of transcranial color-coded Doppler ultrasonography. J Endovasc Ther 2010; 17:556. 27. Bouri S, Thapar A, Shalhoub J, et al. Hypertension and the post-carotid endarterectomy cerebral hyperperfusion syndrome. Eur J Vasc Endovasc Surg 2011; 41:229. 28. Pennekamp CW, Tromp SC, Ackerstaff RG, et al. Prediction of cerebral hyperperfusion after carotid endarterectomy with transcranial Doppler. Eur J Vasc Endovasc Surg 2012; 43:371. 29. Clagett, GP, Robertson, JT. Surgical considerations in symptomatic disease. In: Stroke: Patho physiology, diagnosis and management, Barnett, HJM, Mohr, JP, Stein, BM, Yatsu, FM (Eds), C hurchill Livingstone, New York 1998. p.1209. https://www.uptodate.com/contents/complications-of-carotid-endarterectomy/print 16/26 7/5/23, 11:38 AM Complications of carotid endarterectomy - UpToDate 30. Hosoda K, Kawaguchi T, Ishii K, et al. Prediction of hyperperfusion after carotid endarterectomy by brain SPECT analysis with semiquantitative statistical mapping method. Stroke 2003; 34:1187. 31. Powers AD, Smith RR. Hyperperfusion syndrome after carotid endarterectomy: a transcranial Doppler evaluation. Neurosurgery 1990; 26:56. 32. Dalman JE, Beenakkers IC, Moll FL, et al. Transcranial Doppler monitoring during carotid endarterectomy helps to identify patients at risk of postoperative hyperperfusion. Eur J Vasc Endovasc Surg 1999; 18:222. 33. Fujimoto S, Toyoda K, Inoue T, et al. Diagnostic impact of transcranial color-coded real-time sonography with echo contrast agents for hyperperfusion syndrome after carotid endarterectomy. Stroke 2004; 35:1852. 34. Piepgras DG, Morgan MK, Sundt TM Jr, et al. Intracerebral hemorrhage after carotid endarterectomy. J Neurosurg 1988; 68:532. 35. Sundt TM Jr, Sharbrough FW, Piepgras DG, et al. Correlation of cerebral blood flow and electroencephalographic changes during carotid endarterectomy: with results of surgery and hemodynamics of cerebral ischemia. Mayo Clin Proc 1981; 56:533. 36. Kidwell CS, Saver JL, Mattiello J, et al. Diffusion-perfusion MRI characterization of post- recanalization hyperperfusion in humans. Neurology 2001; 57:2015. 37. Karapanayiotides T, Meuli R, Devuyst G, et al. Postcarotid endarterectomy hyperperfusion or reperfusion syndrome. Stroke 2005; 36:21. 38. Kieburtz K, Ricotta JJ, Moxley RT 3rd. Seizures following carotid endarterectomy. Arch Neurol 1990; 47:568. 39. Doig D, Turner EL, Dobson J, et al. Incidence, impact, and predictors of cranial nerve palsy and haematoma following carotid endarterectomy in the international carotid stenting study. Eur J Vasc Endovasc Surg 2014; 48:498. 40. Payne DA, Twigg MW, Hayes PD, Naylor AR. Antiplatelet agents and risk factors for bleeding postcarotid endarterectomy. Ann Vasc Surg 2010; 24:900. 41. Comerota AJ, Difiore R, Tzilinis A, Chahwan S. Cervical hematoma following carotid endarterectomy is morbid and preventable: a 12-year case-controlled review. Vasc Endovascular Surg 2012; 46:610. 42. Rosenbaum A, Rizvi AZ, Alden PB, et al. Outcomes related to antiplatelet or anticoagulation use in patients undergoing carotid endarterectomy. Ann Vasc Surg 2011; 25:25. 43. Morales Gisbert SM, Sala Almonacil VA, Zaragoz Garc a JM, et al. Predictors of cervical bleeding after carotid endarterectomy. Ann Vasc Surg 2014; 28:366. https://www.uptodate.com/contents/complications-of-carotid-endarterectomy/print 17/26 7/5/23, 11:38 AM Complications of carotid endarterectomy - UpToDate 44. Stone DH, Nolan BW, Schanzer A, et al. Protamine reduces bleeding complications associated with carotid endarterectomy without increasing the risk of stroke. J Vasc Surg 2010; 51:559. 45. Kakisis JD, Antonopoulos CN, Mantas G, et al. Cranial Nerve Injury After Carotid Endarterectomy: Incidence, Risk Factors, and Time Trends. Eur J Vasc Endovasc Surg 2017; 53:320. 46. Tamaki T, Node Y, Saitoum N, et al. Vernet's syndrome after carotid endarterectomy. Perspect Vasc Surg Endovasc Ther 2013; 25:65. 47. Grieff AN, Dombrovskiy V, Beckerman W, et al. Anesthesia Type is Associated with Decreased Cranial Nerve Injury in Carotid Endarterectomy. Ann Vasc Surg 2021; 70:318. 48. Fokkema M, de Borst GJ, Nolan BW, et al. Clinical relevance of cranial nerve injury following carotid endarterectomy. Eur J Vasc Endovasc Surg 2014; 47:2. 49. Cunningham EJ, Bond R, Mayberg MR, et al. Risk of persistent cranial nerve injury after carotid endarterectomy. J Neurosurg 2004; 101:445. 50. Hye RJ, Mackey A, Hill MD, et al. Incidence, outcomes, and effect on quality of life of cranial nerve injury in the Carotid Revascularization Endarterectomy versus Stenting Trial. J Vasc Surg 2015; 61:1208. 51. Wang TK, Bhamidipaty V, MacCormick M. First bite syndrome following ipsilateral carotid endarterectomy. Vasc Endovascular Surg 2013; 47:148. 52. Stone PA, Srivastava M, Campbell JE, et al. A 10-year experience of infection following carotid endarterectomy with patch angioplasty. J Vasc Surg 2011; 53:1473. 53. L onore FT, Elsa F, David PC, et al. Short- and Long-Term Outcomes Following Biological Pericardium Patches Versus Prosthetic Patches for Carotid Endarterectomy: A Retrospective Bicentric Study. Ann Vasc Surg 2021; 72:66. 54. Haddad F, Wehbe MR, Hmedeh C, et al. Bilateral Carotid Patch Infection Occurring 12 years Following Endarterectomy. Ann Vasc Surg 2020; 65:285.e11. 55. Azouz V, Fahmy JN, Kornbau C, Petrinec D. Recurrent pseudoaneurysm after carotid endarterectomy. J Vasc Surg Cases Innov Tech 2019; 5:128. 56. Fatima J, Federico VP, Scali ST, et al. Management of patch infections after carotid endarterectomy and utility of femoral vein interposition bypass graft. J Vasc Surg 2019; 69:1815. 57. Hillman Terzian WT, Schadt S, Sheth SU. Right carotid-cutaneous fistula and right carotid pseudoaneurysm formation secondary to a chronically infected polyethylene terephthalate patch. Int J Crit Illn Inj Sci 2018; 8:48. https://www.uptodate.com/contents/complications-of-carotid-endarterectomy/print 18/26 7/5/23, 11:38 AM Complications of carotid endarterectomy - UpToDate 58. Varetto G, Trevisan A, Barile G, et al. Carotid Pseudoaneurysm After Eversion Endarterectomy: A Case Report and Review of the Literature. Vasc Endovascular Surg 2018; 52:309. 59. Xu JH, Altaf N, Tosenovsky P, Mwipatayi BP. Management challenges of late presentation Dacron patch infection after carotid endarterectomy. BMJ Case Rep 2017; 2017. 60. Naylor R. Management of prosthetic patch infection after CEA. J Cardiovasc Surg (Torino) 2016; 57:137. 61. Menna D, Ruggiero M, Speziale F. Infected pseudoaneurysm after carotid endarterectomy: mismatch between clinical presentation and origin. Ann Vasc Surg 2014; 28:740.e17. 62. Le L, Charlton-Ouw K, Safi HJ, Azizzadeh A. Late expulsion of a Dacron patch after carotid endarterectomy. J Vasc Surg 2012; 56:1721. 63. Mann CD, McCarthy M, Nasim A, et al. Management and outcome of prosthetic patch infection after carotid endarterectomy: a single-centre series and systematic review of the literature. Eur J Vasc Endovasc Surg 2012; 44:20. 64. Zierler RE, Bandyk DF, Thiele BL, Strandness DE Jr. Carotid artery stenosis following endarterectomy. Arch Surg 1982; 117:1408. 65. Elsayed N, Ramakrishnan G, Naazie I, et al. Outcomes of Carotid Revascularization in the Treatment of Restenosis After Prior Carotid Endarterectomy. Stroke 2021; 52:3199. 66. Goodney PP, Nolan BW, Eldrup-Jorgensen J, et al. Restenosis after carotid endarterectomy in a multicenter regional registry. J Vasc Surg 2010; 52:897. 67. Lal BK, Beach KW, Roubin GS, et al. Restenosis after carotid artery stenting and endarterectomy: a secondary analysis of CREST, a randomised controlled trial. Lancet Neurol 2012; 11:755. 68. Hertzer NR, Bena JF. Patching plus extended exposure and tacking of the common carotid cuff may reduce the late incidence of recurrent stenosis after carotid endarterectomy. J Vasc Surg 2013; 58:926. 69. Pavela J, Ahanchi S, Steerman SN, et al. Grayscale median analysis of primary stenosis and restenosis after carotid endarterectomy. J Vasc Surg 2014; 59:978. 70. Chan RC, Chan YC, Cheung GC, Cheng SW. Predictors of restenosis after carotid endarterectomy: 17-year experience in a tertiary referral vascular center. Vasc Endovascular Surg 2014; 48:201. 71. Li Q, Liu B, Zhao Y, et al. Echolucent carotid plaque is associated with restenosis after carotid endarterectomy. J Neurosurg 2020; 134:1203. https://www.uptodate.com/contents/complications-of-carotid-endarterectomy/print 19/26 7/5/23, 11:38 AM Complications of carotid endarterectomy - UpToDate 72. Dakour-Aridi H, Mathlouthi A, Locham S, et al. Predictors of midterm high-grade restenosis after carotid revascularization in a multicenter national database. J Vasc Surg 2020; 71:1972. 73. Edenfield L, Blazick E, Eldrup-Jorgensen J, et al. Outcomes of carotid endarterectomy in the Vascular Quality Initiative based on patch type. J Vasc Surg 2020; 71:1260. 74. Jeong MJ, Kwon SU, Kim MJ, et al. Effects of patient age on outcomes after carotid endarterectomy: A retrospective, single-center study in Korea. Medicine (Baltimore) 2019; 98:e16781. 75. Paraskevas KI, Gloviczki P. The jury is still out on optimal management of restenosis after carotid interventions. J Vasc Surg 2019; 70:339. 76. Dulai M, Tawfick W, Hynes N, Sultan S. Female Gender as a Risk Factor for Adverse Outcomes After Carotid Revascularization. Ann Vasc Surg 2019; 60:254. 77. Edenfield L, Blazick E, Healey C, et al. Long-term impact of the Vascular Study Group of New England carotid patch quality initiative. J Vasc Surg 2019; 69:1801. 78. Okazaki T, Kanematsu Y, Shimada K, et al. A Single-center Retrospective Study with 5- and 10-year Follow-up of Carotid Endarterectomy with Patch Graft. Neurol Med Chir (Tokyo) 2019; 59:231. 79. Texakalidis P, Tzoumas A, Giannopoulos S, et al. Risk Factors for Restenosis After Carotid Revascularization: A Meta-Analysis of Hazard Ratios. World Neurosurg 2019; 125:414. 80. Texakalidis P, Giannopoulos S, Jonnalagadda AK, et al. Carotid Artery Endarterectomy versus Carotid Artery Stenting for Restenosis After Carotid Artery Endarterectomy: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 115:421. 81. Sadideen H, Taylor PR, Padayachee TS. Restenosis after carotid endarterectomy. Int J Clin Pract 2006; 60:1625. 82. Fokkema M, de Borst GJ, Nolan BW, et al. Carotid stenting versus endarterectomy in patients undergoing reintervention after prior carotid endarterectomy. J Vasc Surg 2014; 59:8. 83. Ladowski JS, Shinabery LM, Peterson D, et al. Factors contributing to recurrent carotid disease following carotid endarterectomy. Am J Surg 1997; 174:118. 84. LaMuraglia GM, Stoner MC, Brewster DC, et al. Determinants of carotid endarterectomy anatomic durability: effects of serum lipids and lipid-lowering drugs. J Vasc Surg 2005; 41:762. 85. Hellings WE, Moll FL, De Vries JP, et al. Atherosclerotic plaque composition and occurrence of restenosis after carotid endarterectomy. JAMA 2008; 299:547. https://www.uptodate.com/contents/complications-of-carotid-endarterectomy/print 20/26 7/5/23, 11:38 AM Complications of carotid endarterectomy - UpToDate 86. Pauletto P, Puato M, Faggin E, et al. Specific cellular features of atheroma associated with development of neointima after carotid endarterectomy: the carotid atherosclerosis and restenosis study. Circulation 2000; 102:771. 87. Bond R, Rerkasem K, Naylor AR, et al. Systematic review of randomized controlled trials of patch angioplasty versus primary closure and different types of patch materials during carotid endarterectomy. J Vasc Surg 2004; 40:1126. 88. Bekelis K, Moses Z, Missios S, et al. Indications for treatment of recurrent carotid stenosis. Br J Surg 2013; 100:440. 89. Coscas R, Rhissassi B, Gruet-Coquet N, et al. Open surgery remains a valid option for the treatment of recurrent carotid stenosis. J Vasc Surg 2010; 51:1124. 90. Mansour MA, Kang SS, Baker WH, et al. Carotid endarterectomy for recurrent stenosis. J Vasc Surg 1997; 25:877. 91. Stoner MC, Cambria RP, Brewster DC, et al. Safety and efficacy of reoperative carotid endarterectomy: a 14-year experience. J Vasc Surg 2005; 41:942. 92. Tu J, Wang S, Huo Z, et al. Repeated carotid endarterectomy versus carotid artery stenting for patients with carotid restenosis after carotid endarterectomy: Systematic review and meta-analysis. Surgery 2015; 157:1166. 93. Fokkema M, Vrijenhoek JE, Den Ruijter HM, et al. Stenting versus endarterectomy for restenosis following prior ipsilateral carotid endarterectomy: an individual patient data meta-analysis. Ann Surg 2015; 261:598. 94. Chang H, Rockman CB, Veith FJ, et al. Outcomes of transfemoral carotid artery stenting and transcarotid artery revascularization for restenosis after prior ipsilateral carotid endarterectomy. J Vasc Surg 2022; 75:561. Topic 15843 Version 20.0 https://www.uptodate.com/contents/complications-of-carotid-endarterectomy/print 21/26 7/5/23, 11:38 AM Complications of carotid endarterectomy - UpToDate GRAPHICS Nerve supply of the thyroid gland It is critical that the superior and recurrent laryngeal nerves be routinely identified and protected in thyroid surgery to reduce the risk of injury. Graphic 82397 Version 4.0 https://www.uptodate.com/contents/complications-of-carotid-endarterectomy/print 22/26 7/5/23, 11:38 AM Complications of carotid endarterectomy - UpToDate Variations in nerve supply of the thyroid gland (A) The external branch of the superior laryngeal nerve innervates the inferior constrictor and cricothyroid muscles. The external branch travels with the superior thyroid artery until approximately 1 cm before the artery enters the superior thyroid pole and then divides into branches that enter the lateral inferior pharyngeal constrictor muscle and the cricothyroid muscle. A few smaller branches may be seen entering the superior thyroid. (B) The RLN is associated with the inferior thyroid artery at approximately the junction of the lower and middle thirds of the thyroid gland. On the left, the RLN ascends in the tracheoesophageal groove and crosses deep to the inferior thyroid artery; on the right, the RLN crosses more obliquely and is oriented more laterally than caudally. While the nerve most often crosses deep to the inferior thyroid artery, documented variations include passing anterior to the artery as well as passing between branches of the inferior thyroid artery. Another variation of the nerve is the nonrecurrent laryngeal nerve, in which the https://www.uptodate.com/contents/complications-of-carotid-endarterectomy/print 23/26 7/5/23, 11:38 AM Complications of carotid endarterectomy - UpToDate laryngeal nerve branches directly from the vagus nerve. This variation occurs more commonly on the right side. STA: superior thyroid artery; IPC: inferior pharyngeal constrictor muscle; CT: cricothyroid muscle. (A) Adapted from: Morton RP, Whit eld Al-Ali S. Anatomical and surgical considerations of the external branch of the superior laryngeal nerve: a systematic review. Clin Otolaryngol 2006; 31:368-374. (B) Adapted from: Makay O, Icoz G, Yilmaz M, Akyildiz M, Yetkin E. The recurrent laryngeal nerve and the inferior thyroid artery-anatomical variations during surgery. Langenbecks Arch Surg 2008; 393:681. Graphic 61802 Version 9.0 https://www.uptodate.com/contents/complications-of-carotid-endarterectomy/print 24/26 7/5/23, 11:38 AM Complications of carotid endarterectomy - UpToDate Proximity of thyroid nerves to vascular structure in the neck n: nerve; a: artery; R: right; L: left. Graphic 139715 Version 1.0 https://www.uptodate.com/contents/complications-of-carotid-endarterectomy/print 25/26 7/5/23, 11:38 AM Complications of carotid endarterectomy - UpToDate Contributor Disclosures Jeffrey Jim, MD, MPHS, FACS Consultant/Advisory Boards: Endospan [Aortic interventions]; Medtronic [Aortic interventions]; Silk Road Medical [Carotid stent]. All of the relevant financial relationships listed have been mitigated. John F Eidt, MD Grant/Research/Clinical Trial Support: Syntactx [Clinical events, data/safety monitoring for medical device trials]. All of the relevant financial relationships listed have been mitigated. Joseph L Mills, Sr, MD No relevant financial relationship(s) with ineligible companies to disclose. Scott E Kasner, MD Grant/Research/Clinical Trial Support: Bayer [Stroke]; Bristol Meyers Squibb [Stroke]; Medtronic [Stroke]; WL Gore and Associates [Stroke]. Consultant/Advisory Boards: Abbvie [Stroke]; AstraZeneca [Stroke]; BMS [Stroke]; Diamedica [Stroke]; Medtronic [Stroke]. All of the relevant financial relationships listed have been mitigated. Kathryn A Collins, MD, PhD, FACS No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/complications-of-carotid-endarterectomy/print 26/26