Surgical Outcomes of Carotid Endarterectomy in Patients with Twisted Carotid Bifurcation: Focus on Postoperative Nerve Complications

Twisted carotid bifurcation, a condition in which the internal carotid artery is positioned medially to the external carotid artery at the carotid bifurcation, is one of the anatomical variations encountered during carotid endarterectomy. Although previous studies have suggested that carotid endarterectomy can be performed safely in twisted carotid bifurcation cases, few have focused on postoperative neurological complications. Therefore, this study aimed to evaluate postoperative neurological complications in carotid endarterectomy cases with twisted carotid bifurcation. This study included patients who underwent carotid endarterectomy at Takikawa Neurosurgical Hospital between January 2012 and July 2024. Twisted carotid bifurcation was diagnosed using preoperative computed tomography angiography images. In twisted carotid bifurcation cases, the internal carotid artery was rotated laterally toward the external carotid artery before endarterectomy. Postoperative complications were compared between the twisted carotid bifurcation group and the normal anatomy group. Of the 143 patients who underwent carotid endarterectomy procedures, 31 cases (20.3%) were diagnosed with twisted carotid bifurcation. The incidence of postoperative hoarseness was significantly higher in the twisted carotid bifurcation group (25.8%) compared with the normal anatomy group (8.2%) (p = 0.012). All cases of hoarseness were transient and resolved by the first outpatient follow-up visit after discharge. There were no differences between the 2 groups in the incidence of other postoperative complications. Patients with twisted carotid bifurcation undergoing carotid endarterectomy have a higher risk of postoperative hoarseness compared with those with normal anatomy. However, the hoarseness was transient, and there were no differences in other postoperative complications. With detailed preoperative planning and careful surgical technique, carotid endarterectomy can be performed safely in patients with twisted carotid bifurcation.