Patching plus extended exposure and tacking of the common carotid cuff may reduce the late incidence of recurrent stenosis after carotid endarterectomy

Abstract

The safety and durability of carotid endarterectomy (CEA) require attention to certain technical details that may evolve over time. The objective of this study was to determine whether routine patch angioplasty and precautions related to the common carotid cuff could reduce the risks for perioperative stroke, internal carotid artery (ICA) thrombosis, or recurrent carotid stenosis. The senior author (N.H.) performed 1959 consecutive isolated CEAs at the Cleveland Clinic from 1976 to 2004. This series can be divided into three distinct eras with respect to patching and management of the proximal common carotid cuff: (1) primary arteriotomy closure with selective patching in only 38 of 653 CEAs (5.8%) from 1976 to 1983 (group 1); (2) routine patching without any special precautions related to the common carotid cuff in 568 CEAs from 1983 to 1990 (group 2); and (3) routine patching with extended exposure and tacking sutures to secure the carotid cuff in 738 CEAs from 1990 to 2004 (group 3). Although vein patching alone seemed to have less risk for perioperative stroke (1.2% vs 2.4%) or ICA thrombosis (0.6% vs 1.8%) than primary closure, these differences did not attain statistical significance. There also were no significant differences in the perioperative stroke and ICA thrombosis rates among the three eras in which changes occurred in patch use and in the management of the carotid cuff. After adjusting for the various lengths of follow-up in the study groups, however, group 3 had a significantly lower risk for recurrent 60% to 99% stenosis or ICA occlusion at >5 years after CEA (odds ratio [OR], 0.09; 95% confidence interval [CI], 0.04-0.22; P < .001). On multivariable analysis, group 3 (OR, 0.23; 95% CI, 0.09-0.60; P = .003) and advancing age (OR, 0.89 per year; 95% CI, 0.85-0.92 per year; P < .001) had less risk for late recurrent stenosis, whereas this risk was higher in women (OR, 2.23; 95% CI, 1.23-4.06; P = .009) and in patients who had undergone previous ipsilateral CEA (OR, 6.02; 95% CI, 1.63-22.2; P = .007). Routine patching plus extended exposure and tacking of the common carotid cuff appear to significantly reduce the long-term incidence of recurrent 60% to 99% stenosis or ICA occlusion after CEA.