Randomized trial of vein versus dacron patching during carotid endarterectomy

Abstract

Abstract Background A recent overview has indicated that, while routine patching is safer than primary closure following carotid endarterectomy (CEA), there is no systematic evidence that patch type influences outcome. Most surgeons perceive that prosthetic patches are more thrombogenic than vein patches. This study tested the hypothesis that it is the patient who is prothrombotic rather than the nature of the patch. Methods Some 274 patients undergoing 276 CEAs were randomized to either dacron (Du Pont, Stevenage, UK) patch closure (n = 137) or vein patch closure (n = 139). All patients with an accessible cranial window were monitored for 3 h after operation using transcranial Doppler (TCD) ultrasonography. The number and rate of embolizations were quantified, together with the requirement for selective dextran therapy to control high rates of postoperative embolization. All patients were assessed after operation and again at 30 days by a neurologist, and all underwent duplex imaging at 30 days. Results The 30-day death or any stroke rate was 2·2 per cent for dacron-patched patients and 3·6 per cent for vein-patched patients (P = 0·72). Dacron-patched patients had a higher incidence of postoperative emboli (median 5 (interquartile range 0–10·5)), compared with a median of 3 (interquartile range 1–17) for vein (P = 0·028). However, the incidence of detecting more than 50 emboli was virtually identical and patch type had no effect on the incidence of sustained high-rate embolization requiring dextran therapy (5·3 per cent for dacron versus 3·7 per cent for vein). No patient had a carotid thrombosis at 30 days. Conclusion Sustained high-rate embolization, previously shown to be highly predictive of progression to carotid thrombosis, appears to be patient dependent rather than related to patch type.