Surgical Management of Penetrating Carotid Artery Injury: Preoperative Level of Consciousness Does Matter

Background: The optimal surgical management of penetrating carotid artery injuries (PCAIs) remains controversial. This study aimed to examine the association between operative techniques for PCAI and the incidence of stroke.

Study design: This retrospective cohort study used the American College of Surgeons TQIP (2016 to 2021) database. We included patients (age 16 years or older) with severe penetrating injuries to the common or internal carotid arteries (CCA/ICA) who underwent one of the following operative procedures: primary suture repair, ligation, and arterial reconstruction with a graft. Multivariate logistic regression analysis with cluster-adjusted-robust SEs was performed to estimate the adjusted odds ratio (AOR) for postoperative stroke stratified by the initial Glasgow Coma Scale (GCS).

Results: A total of 492 patients were included (329 underwent primary suture repair, 82 underwent ligation, and 81 underwent arterial reconstruction with a graft). The median age was 31 years (interquartile range 24 to 43) and median GCS on arrival was 11 (interquartile range 3 to 15). On multivariate analysis after adjusting for potential confounders, ligation of CCA/ICA was significantly associated with increased odds of stroke in patients with initial GCS ≥9 (AOR: 4.40, 95% CI 1.16 to 16.58, p = 0.029), whereas there was no significant association in patients with GCS <9 (AOR 0.77, 95% CI 0.28 to 2.11, p = 0.37). No significant association was identified between arterial reconstruction with a graft and stroke, irrespective of the initial GCS.

Conclusions: The study findings suggest that the preoperative level of consciousness may help in planning operative strategies for PCAI. In patients with an initial GCS ≥9, definitive repair of the CCA/ICA, including arterial reconstruction with a graft, should be pursued instead of ligation.