Patch angioplasty versus primary closure for carotid endarterectomy.

Abstract

Carotid patch angioplasty (with either a venous or a synthetic patch) may reduce the risk of carotid artery restenosis and subsequent ischaemic stroke. The objective of this review was to assess the effect of routine or selective carotid patch angioplasty compared to carotid endarterectomy with primary closure. We searched the Cochrane Stroke Group trials register, Medline (1966 to 1995), Embase (1980 to 1995) and Index to Scientific and Technical Proceedings (1980 to 1994). We handsearched Annals of Surgery (1981 to 1995), British Journal of Surgery (1985 to 1995), European Journal of Vascular and Endovascular Surgery (1987 to 1995) and World Journal of Surgery (1978 to 1995). Randomised trials comparing carotid patch angioplasty with primary closure in any patients undergoing carotid endarterectomy. Two reviewers independently assessed eligibility, trial quality and extracted the data. Six trials involving 794 patients and 882 operations were included. The quality of trials was generally poor. Follow-up varied from hospital discharge to five years. Carotid patch angioplasty showed a reduction in the risk of stroke of any type, ipsilateral stroke, and stroke or death, during the perioperative period and longterm follow-up. However, data were not available from all trials, the number of events was small and there was significant loss to follow-up. Patching appeared to reduce the risk of perioperative arterial occlusion (six trials, odds ratio 0.17, 95% confidence interval 0.06 to 0.46). Patching was also associated with decreased restenosis during longterm follow-up in five trials, (odds ratio 0.32, 95% confidence interval 0.19 to 0.53). However, these results are uncertain because of loss to follow-up and the small number of events. Very few arterial complications, including haemorrhage, infection, cranial nerve palsies and pseudo-aneurysm formation were recorded with either patch or primary closure. Limited evidence suggests that carotid patch angioplasty may lower the risk of perioperative arterial occlusion and restenosis. It is unclear whether this reduces the risk of death or stroke.