Management of the carotid arteries during carotid and vagal paraganglioma surgery

Surgery for carotid and vagal paraganglioma presents a high risk for carotid artery injury. The authors' objective was to describe a strategy for preoperative evaluation, risk stratification, and operative management of the carotid arteries when operating on carotid and vagal paraganglioma. They suggest stratifying patient risk for carotid artery involvement first according to the tumor׳s Shamblin group. Those with low Shamblin grade and no other concerning anatomic features need no preoperative carotid evaluation. Those at moderate anatomic risk benefit from preoperative temporary balloon test occlusion, whereas those at high risk should routinely have shunts placed intraoperatively. A variety of shunts are available, and surgeons should be prepared to place them in any patient. Saphenous vein or prosthetic grafts can be used to reconstruct the internal carotid artery, if necessary, and the external carotid artery can be ligated. In patients at high risk for carotid involvement and in whom carotid shunting or reconstruction may be difficult, preoperative carotid stent placement, internal to external carotid bypass, and nonoperative tumor treatment strategies should be considered. The authors conclude that surgeons performing carotid and vagal paraganglioma surgery should be prepared for carotid artery involvement in all patients. They recommend a strategy of preoperative risk stratification according to Shamblin group and temporary balloon test occlusion and surgeon familiarity with techniques for carotid shunting and reconstruction.