Results of Carotid Endarterectomy with Pericardial Patch Angioplasty: Rate and Predictors of Restenosis

Abstract

Routine patch angioplasty after carotid endarterectomy (CEA) is believed to decrease the incidence of recurrent stenosis. The results of autogenous vein, Dacron, and PTFE used as a patch material have been described. Bovine pericardium has more recently been introduced as a patch material. We studied 61 of 73 consecutive patients who underwent isolated CEA with pericardial patch angioplasty to determine the incidence of restenosis and variables associated with restenosis. All patients had intraoperative completion duplex examination performed, and no patient had residual stenosis or anatomic defects at the end of the procedure. All procedures were performed under general anesthesia with the use of a Javid shunt. Mean age was 72.8 +/- 7.8 years, 41% were female, and 62% were asymptomatic. Hypertension was present in 72%, elevated cholesterol in 80%, and history of coronary artery disease in 44%. Recurrent stenosis of >50% was considered to be significant. Our study focuses on 61 of 73 patients who had follow-up duplex ultrasound data available. There were no perioperative neurologic events, reoperations for bleeding, or deaths. Mean duplex follow-up available in 61 patients was 13.1 +/- 5.1 months. Thirty-six patients had 1-15% stenosis, 15 patients had 16-49%, and 10 patients had 50-79%. In the 50-79% group, the mean systolic velocity was 154 +/- 25 cm/sec and the mean end diastolic velocity (EDV) was 36 +/- 16 cm/sec. The highest EDV in the 50-79% group was 56 cm/sec. No patients had stenosis in the 80-99% range. There were no late neurologic events and no late reinterventions. Kaplan-Meier restenosis-free survival at 1 year was 95.6%. Significant univariate predictors of recurrent stenosis of >50% were younger age (68 vs. 74 years, p = 0.04) and presence of preoperative symptomatic disease (35% vs. 5%, p = 0.004). Stepwise multiple logistic regression indicated the most significant predictor of restenosis was the presence of preoperative symptoms (p = 0.008). Stepwise Cox regression analysis also showed preoperative symptomatic status was the only significant factor for restenosis (p = 0.019), with a relative risk of 6.65 and a 95% confidence interval of 1.36-32.4. In conclusion, pericardial patch angioplasty is associated with minimal early adverse events. Restenosis with pericardial patch angioplasty is not uncommon, but high-grade restenosis did not occur in this study. The presence of preoperative symptoms and younger age were the most significant predictors of restenosis.