Carotid Artery Remodeling After Modified Eversion Carotid Endarterectomy

Abstract

Modified eversion carotid endarterectomy (meCEA) is an alternative to classical patch angioplasty or eversion. An meCEA involves everting the carotid plaque through a longitudinal incision over the common carotid artery without transecting the internal carotid artery (ICA). Those who advocate patch angioplasty cite the propensity of luminal narrowing from the procedure or restenosis as a reason to avoid primary repair. We seek to objectively quantify the outcome of the carotid artery after primary repair of the longitudinal incision employed in this technique. We retrospectively reviewed all meCEAs performed at our institution and included those with preoperative and postoperative computerized tomography angiography. Pre- and postoperative centerline measurements, by two independent observers, were obtained at 1 cm and 2 cm proximal to the ICA ostium within the common carotid artery (CCA), the ICA ostium, and 1 cm and 2 cm distally within the ICA. The sum of the diameter changes at each segment was defined as the overall remodeling (OR). Segmental remodeling of the CCA and ICA (ICAR) were defined as the sum of the CCA and ICA changes, respectively. In total, 40 individual carotid arteries treated with meCEA with both pre- and postoperative computerized tomography angiographies (over a range of 0-1183 days) were included. On average, the ICA diameter increased by 5% at its ostium, 12.6% and 9.3% at 1 cm and 2 cm distal to its ostium, respectively. The CCA decreased in diameter, −8% and −3% at 1 cm and 2 cm proximal to the bifurcation, respectively. OR was −0.81 mm for the entire cohort, predominantly driven by remodeling of the CCA (−1.51 mm), whereas ICAR was favorable at +0.48 mm. Interestingly, female patients had more favorable remodeling overall, with less narrowing of the CCA (−0.96 mm vs −1.51 mm in male patients) and positive ICAR compared with preoperative imaging (+1.58 mm vs −0.25 mm in male patients). We found that postoperatively, despite a decreased segmental diameter of the CCA after meCEA, the ICA diameter remains largely intact and also remodels favorably over time. Our findings suggest that meCEA does not yield adverse narrowing of the ICA after primary repair or significant restenosis in this series. Although there may be a gender-related difference in OR, more evaluation is necessary.TablePostendarterectomy percent change in diameter of the common and internal carotid arteries at five locationsOverall cohort (N = 40)% change in diameterCCA 2 cm from bifurcation−3.3CCA 1 cm from bifurcation−8.2Ostial ICA+5.1ICA 1 cm from bifurcation+12.6ICA 2 cm from bifurcation+9.3Male (n = 24) CCA 2 cm from bifurcation−2.8 CCA 1 cm from bifurcation−9.4 Ostial ICA+1.0 ICA 1 cm from bifurcation+1.9 ICA 2 cm from bifurcation+5.5Female (n = 16) CCA 2 cm from bifurcation−4.1 CCA 1 cm from bifurcation−6.4 Ostial ICA+11.3 ICA 1 cm from bifurcation+28.7 ICA 2 cm from bifurcation+14.9CCA, Common carotid artery; ICA, internal carotid artery. Open table in a new tab