Elsevier

World Neurosurgery

Volume 129, September 2019, Pages 503-513.e2
World Neurosurgery

Literature Review
Role of Preoperative Embolization in Carotid Body Tumor Surgery: A Systematic Review and Meta-Analysis

https://doi.org/10.1016/j.wneu.2019.05.209Get rights and content

Background

Carotid body tumors (CBTs) are highly vascularized tumors which can render tumor resection surgery challenging. There is evidence suggesting that preoperative selective embolization can reduce blood loss during surgery and decrease the risk of perioperative complications; however, recent reports have questioned the benefits that preoperative embolization provides. The objective of this study is to investigate the impact of preoperative embolization on CBT surgical resection.

Methods

This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eligible studies were identified through a search of PubMed, Scopus, and Cochrane Central Register of Controlled Trials until March 2019. A random effects model meta-analysis was conducted, and the I2 statistic was used to assess for heterogeneity.

Results

Twenty-five studies comprising 1326 patients were included. Patients who received preoperative embolization had statistically significant lower intraoperative blood loss (weighted mean difference [WMD], −135.32; 95% confidence interval [CI], −224.58 to −46.06; I2 = 78.6%). Duration of the procedure was statistically significantly shorter in the preembolization group than the nonembolization group (WMD, −38.61; 95% CI, −65.61 to −11.62; I2 = 71.9%). There were no differences in the rates of cranial nerve (CN) injuries (odds ratio [OR], 1.13; 95% CI, 0.68–1.86; I2 = 12.9%), stroke (OR, 1.75; 95% CI, 0.70–4.36; I2 = 0%), transient ischemic attacks (TIAs) (OR, 0.55; 95% CI, 0.11–2.65; I2 = 0%), or length of stay (WMD, 0.32; 95% CI, −1.35 to 1.98; I2 = 96.4%) between the 2 groups.

Conclusions

Patients who received embolization prior to CBT resection had statistically significant lower blood loss and shorter duration of operation. The rates of CN palsy, stroke, TIA, and length of stay were similar between patients who had preoperative embolization and those who did not.

Introduction

Paragangliomas are a subset of neuroendocrine tumors in the extra-adrenal paraganglia that arise from the embryonic neural crest cells.1, 2 Carotid paragangliomas, commonly referred as carotid body tumors (CBTs), are the most common neuroendocrine tumors in the head and neck.3 They are most commonly located at the bifurcation of the common carotid artery and usually present as a painless neck mass; however, larger CBTs can present with cranial nerve (CN) palsies.4 Most CBTs are benign in nature and present during the third or fourth decade of life.2

Carotid paragangliomas are highly vascularized tumors which can make tumor resection particularly challenging.5 Specifically, vascular and neurologic sequelae are feared complications of CBT surgical therapy.6 Schick et al.7 first introduced the concept of preoperative embolization in 1980 and reported the first such CBT resection. Since then, several studies have evaluated the impact of preoperative embolization on CBT surgery.5, 8, 9 There is evidence suggesting that preoperative selective embolization may reduce blood loss during surgery and decrease the risk of perioperative complications10; however, recent reports have cast doubt and questioned the benefits preoperative embolization may provide.11

The aim of this systematic review and meta-analysis was to synthesize all comparative studies that investigated the impact of preoperative embolization on CBT surgical resection and identify whether there is a temporal component of embolization that can affect postoperative outcomes.

Section snippets

Methods

This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.12

Search Results

The literature search yielded 406 potentially relevant records after duplicates were removed. After screening titles and abstracts, 52 articles were retrieved for full-text evaluation. Twenty-five studies met the predetermined eligibility criteria and were included in the meta-analysis as shown in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram (Figure 1).

Characteristics of the Included Studies

All 25 studies were retrospective observational cohort analyses and comprised a total of 1326 patients

Discussion

This meta-analysis showed that patients who received embolization prior to CBT resection had statistically significant lower blood loss and shorter duration of operation. The rates of CN palsy, stroke, TIA, and length of stay were similar between patients who had preoperative embolization and those who did not.

It has been already shown that complications of carotid body paraganglioma resection are associated with increased tumor size.38 These tumors, although mostly benign, usually require

Conclusions

The present meta-analysis showed that embolization prior to CBT resection is associated with statistically significant lower blood loss and shorter duration of operation compared with patients who did not have preoperative embolization. However, it is unknown whether these differences are clinically significant. CN palsy, stroke, TIA, and length of stay were similar between the 2 groups. Future studies should provide outcomes based on tumor size and Shamblin classification and investigate the

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

    Pavlos Texakalidis and Nektarios Charisis are co–first authors.

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