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4 . 2025

Comparison of antejugular and retrojugular approaches to the carotid bifurcation: a prospective randomized study

Abstract

Carotid endarterectomy is the gold standard for stroke prevention. Although it is one of the most common procedures in vascular surgery, its technique has not been fully standardized. In particular, there is no consensus on the optimal approach for dissection of the carotid bifurcation. Data suggest differences in the safety and efficacy of the retrojugular and/or antejugular approaches, primarily regarding local wound complications and the incidence of cranial nerve injuries, which occur in 1.4–31% of cases and significantly impair patients’ quality of life.

Objective. To compare the safety and efficacy of the antejugular and retrojugular approaches to the carotid bifurcation within a prospective randomized study.

Material and methods. The study enrolled 280 patients (140 retrojugular, 140 antejugular). Inclusion criteria: internal carotid artery (ICA) stenosis >70% (asymptomatic) or >50% (symptomatic). Exclusion criteria: primary – pre-existing neurological deficits, reoperations. secondary – perioperative stroke, wound hematomas, early reinterventions. Design: Prospective randomized study.

Results. Common complications: perioperative acute cerebral circulatory disorders/transient ischemic attacks – 2.14%/1.43% with antejugular access, 1.43%/0.71% with retrojugular access (p=0.658/0.566); hematomas – 0.7%/2.1%, respectively (p=0.63). Local neurological symptoms: on day 1 – 33.8% (dysphonia – 33.1%, vocal fold paresis – 1.9%), on day 3 – 22.9%, after 3 months – complete regression in all patients. After applying the secondary exclusion criteria, 134 patients with retrojugular access and 132 patients with antejugular access were included in the comparative analysis. The frequency of cranial nerve damage, dysphonia, and dysphagia did not differ depending on the type of access (p>0.05). The surgery time was 76.1±1.8 min (antejugular) vs 74.2±2.4 min (retrojugular, p=0.51).

Conclusion. The retrojugular approach facilitates internal carotid artery exposure and obviates venous ligation but does not reduce local neurological complications or operative duration compared to the antejugular approach. Both techniques demonstrate comparable safety profiles, with approach selection contingent on surgeon preference and patient-specific anatomy.

Keywords: carotid endarterectomy; local neurological complications; cranial nerve injuries; anterjugular approach; retrojugular approach

Funding. The study was not sponsored.

Conflict of interest. The authors declare no conflict of interest.

Authors’ contributions. Study conception and design – Maksimov A.V.; data collection and handling – Nuretdinov R.M., Plotnikov M.V.; processing of the material – Mullakhmetov R.M.; draft manuscript preparation – Mullakhmetov R.M., Nuretdinov R.M.; manuscript revision – Maksimov A.V.

For citation: Maksimov A.V., Mullakhmetov R.M., Nuretdinov R.M., Plotnikov M.V. Comparison of Antejugular and Retrojugular Approaches to the Carotid Bifurcation: A Prospective Randomized Study. Angiology and Vascular Surgery. Journal named after Academician A.V. Pokrovsky. 2025; 31 (4): 55–61. DOI: https://doi.org/10.33029/1027-6661-2025-31-4-55-61

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CHIEF EDITOR
CHIEF EDITOR
Yuri V. Belov
Academician of the Russian Academy of Sciences Doctor of Medical Sciences, Professor, President of the Russian Society of Angiologists and Vascular Surgeons

 

In accordance with the decision of the Presidium of the Russian Society of Angiologists and Vascular Surgeons, the journal "Angiology and Vascular Surgery" will be named after Academician A.V. Pokrovsky starting from No. 2/2022.

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