Posterior transverse plication technique for treatment of redundant internal carotid artery during endarterectomy

Abstract

Purpose: Posterior transverse plication (PTP) has gained popularity as a technique to correct redundancy of the internal carotid artery during endarterectomy. The safety of this technique in large series of patients has not been extensively studied. We investigated 876 primary carotid endarterectomies (CEAs) performed at our institution over the last six years to determine the safety of this technique. Methods: Indication for surgery was carotid stenosis ≥70% in 341 (39%) symptomatic and 535 (61%) asymptomatic cases. Preoperative imaging consisted of duplex ultrasound alone or combined with magnetic resonance angiography. Patients were divided into four groups related to surgical technique: CEA+PTP+8 mm patch (group Ia), CEA+PTP+10 mm patch (group Ib), CEA+patch (group II) and CEA+primary closure (group III). There were 43, 39, 581 and 213 patients in groups Ia, Ib, II and III, respectively. No statistical differences in age, sex or risk factors for atherosclerotic disease were noted among the groups. Postoperative duplex ultrasonography was used at 2 weeks and every 6 months thereafter to evaluate the adequacy of the repair and presence of complications such as pseudoaneurysm formation and extrinsic compression by the excluded carotid segment. Results: The 30-day mortality was 1.2%, 0.6% and 0.3% for groups I, II and III, respectively. Stroke rates for the same period were 0%, 0.6% and 0.8% for groups I, II and III, respectively. Duplex ultrasonography demonstrated significant stenosis (≥50%) in two (5%) patients in group Ia at 12 months. No restenosis was observed in group Ib. For groups II and III the rates of restenosis were 1.5% and 0.8%. One patient in group II developed a pseudoaneurysm after 7 months. Conclusion: Posterior transverse plication safely corrects redundancy of the internal carotid artery during endarterectomy without causing early significant restenosis. Continued follow-up in a larger group of patients to determine long-term efficacy and correlation between patch size and restenosis rate is warranted.