Surgery for Carotid Artery Stenosis following Neck Irradiation Mark L. Friedell, MD, Brian P. Joseph, MD, Michael J. Cohen, MD, and John D. Horowitz, MD, Orlando, Florida ANNALSo/ VASCULAR SURGERY - - i InternationnlJournal of Vascular Surgery I Carotid angioplasty and stenting (CAS) is being promoted for patients with carotid artery ste- nosis who have received neck irradiation. We reviewed our experience with carotid endarter- ectomy (CEA) following neck irradiation to determine if indeed postoperative and long-term problems were an issue in these patients. Over the past 13 years, 10 patients with a history of neck irradiation underwent 11 procedures. The average time interval between radiation treat- ment and surgery was 14 years (range 1-44). All carotid arteries were repaired with a standard endarterectomy, eight of which were patched. Three patients had undergone a radical neck dissection on the side ipsilateral to the carotid lesion. They received a pectoral myocutaneous flap (PMF) to protect the carotid artery and optimize wound healing. The lack of perioperative complications and of morbidity indicate that carotid reconstruction for patients with previous neck irradiation is safe and durable. Until long-term favorable results with CAS are available for these patients, operative intervention should remain the standard treatment. INTRODUCTION Surgeons have traditionally approached carotid ar- tery stenoses through a previously irradiated neck with some trepidation. The concerns have always centered around possible absent tissue planes, ra- diation arteritis, and problems with healing of the carotid artery and the overlying wound. Many of these patients have also undergone radical neck dis- section (RND) and/or laryngectomy with place- ment of a permanent tracheostomy stoma, further complicating the nature of the subsequent carotid surgery. With the advent of new technology, ca- Department of Surgical Education, Orlando Regional Medical Cen- ter, Orlando, FL. Presented at the Twenty-fifth Annual Meeting of the Peripheral Vascular Surgery Society, Toronto, Ontario, Canada, June 10, 2000. Correspondence to: Mark L. Friedell, MD, 86 W Underwood Street, Suite 201, Orlando, FL 32806, USA. Ann Vasc Surg 2001; 15:13-18 DOs 10.I007/s100160010009 9 Annals of Vascular Surgery Inc. Published online: December 22, 2000 rotid angioplasty and stenting (CAS) has been sug- gested as an alternative approach to carotid artery stenosis in the irradiated neck in an effort to avoid the possible pitfalls of surgery in this setting. We decided to review our experience with carotid re- construction in the irradiated neck to see if our sur- gical approach was successful, or if we needed to consider alternative management strategies such as CAS. PATIENTS AND METHODS The list of patients who underwent carotid recon- struction by three vascular surgeons between 1987 and 2000 was reviewed. Ten patients were identi- fied who had been treated previously with neck irradiation for cancer. Eleven reconstructions were performed. All the clinical and demographic data were gathered by chart review, office visits, and telephone interviews (Table I). RESULTS The mean patient age was 70 years (60-82) and 90% of patients were men, all with a previous 13