Carotid Patch Angioplasty Research Articles

Patch angioplasty versus primary closure for carotid endarterectomy.

Carotid patch angioplasty may reduce the risk of acute occlusion or long-term restenosis of the carotid artery and subsequent ischaemic stroke in people undergoing carotid endarterectomy (CEA). This is an update of a Cochrane Review originally published in 1995 and updated in 2008. To assess the safety and efficacy of routine or selective carotid patch angioplasty with either a venous patch or a synthetic patch compared with primary closure in people undergoing CEA. We wished to test the primary hypothesis that carotid patch angioplasty results in a lower rate of severe arterial restenosis and therefore fewer recurrent strokes and stroke-related deaths, without a considerable increase in perioperative complications. We searched the Cochrane Stroke Group trials register, CENTRAL, MEDLINE, Embase, two other databases, and two trial registries in September 2021. Randomised controlled trials and quasi-randomised trials comparing carotid patch angioplasty with primary closure in people undergoing CEA. Two review authors independently assessed eligibility and risk of bias; extracted data; and determined the certainty of evidence using the GRADE approach. Outcomes of interest included stroke, death, significant complications related to surgery, and artery restenosis or occlusion during the perioperative period (within 30 days of the operation) or during long-term follow-up. We included 11 trials involving 2100 participants undergoing 2304 CEA operations. The quality of trials was generally poor. Follow-up varied from hospital discharge to five years. Compared with primary closure, carotid patch angioplasty may make little or no difference to reduction in risk of any stroke during the perioperative period (odds ratio (OR) 0.57, 95% confidence interval (CI) 0.31 to 1.03; P = 0.063; 8 studies, 1769 participants; very low-certainty evidence), but may lower the risk of any stroke during long-term follow-up (OR 0.49, 95% CI 0.27 to 0.90; P = 0.022; 7 studies, 1332 participants; very low-certainty evidence). In the included studies, carotid patch angioplasty resulted in a lower risk of ipsilateral stroke during the perioperative period (OR 0.31, 95% CI 0.15 to 0.63; P = 0.001; 7 studies, 1201 participants; very low-certainty evidence), and during long-term follow-up (OR 0.32, 95% CI 0.16 to 0.63; P = 0.001; 6 studies, 1141 participants; very low-certainty evidence). The intervention was associated with a reduction in the risk of any stroke or death during long-term follow-up (OR 0.59, 95% CI 0.42 to 0.84; P = 0.003; 6 studies, 1019 participants; very low-certainty evidence). In addition, the included studies suggest that carotid patch angioplasty may reduce the risk of perioperative arterial occlusion (OR 0.18, 95% CI 0.08 to 0.41; P < 0.0001; 7 studies, 1435 participants; low-certainty evidence), and may reduce the risk of restenosis during long-term follow-up (OR 0.24, 95% CI 0.17 to 0.34; P < 0.00001; 8 studies, 1719 participants; low-certainty evidence). The studies recorded very few arterial complications, including haemorrhage, infection, cranial nerve palsies and pseudo-aneurysm formation, with either patch or primary closure. We found no correlation between the use of patch angioplasty and the risk of either perioperative or long-term stroke-related death or all-cause death rates. Compared with primary closure, carotid patch angioplasty may reduce the risk of perioperative arterial occlusion and long-term restenosis of the operated artery. It would appear to reduce the risk of ipsilateral stroke during the perioperative and long-term period and reduce the risk of any stroke in the long-term when compared with primary closure. However, the evidence is uncertain due to the limited quality of included trials.

For people undergoing carotid patch angioplasty, how do synthetic and vein patches compare?

For people undergoing carotid patch angioplasty, how do synthetic and vein patches compare?

Patches of different types for carotid patch angioplasty.

Patches of different types for carotid patch angioplasty.

Usefulness of Radial Artery as a Carotid Artery Patch in Simultaneous Carotid Endarterectomy and Coronary Artery Bypass Graft Operation with Complete Arterial Revascularization.

Serious coronary artery diseases including left main coronary artery disease, proximal left anterior descending artery disease, and three-vessel coronary artery disease with carotid artery stenosis are required simultaneous operations. By using complete arterial revascularization technique for coronary artery bypass graft operation, radial artery can be used safely as a patch material for carotid endarterectomy in combined surgery. Between 2016 and 2018, 14 patients who had serious coronary artery disease with the stenosis of unilateral carotid artery equal/over 70% were included in the study. Complete arterial revascularization was performed in all patients and radial artery was used as a patch material in carotid endarterectomy. All patients were discharged without any complication and carotid artery colored Doppler ultrasound was performed to the patients in the 3rd months, 6th months, and first year of the operation. There was no restenosis detected. In conclusion, radial artery is useable for carotid patch angioplasty in patients who underwent simultaneous carotid endarterectomy and coronary artery bypass graft operation with complete arterial revascularization. Further studies including a large number of patients are needed to examine the long-term patency of this graft.

VASCULAR PATCHES FOR ARTERIAL RECONSTRUCTION, CHALLENGES AND ADVANCED TECHNOLOGIES

High prevalence of internal carotid atherosclerosis and recent advances in its diagnosis result in an increase in the annual number of carotid endarterectomy procedures to restore carotid patency. Various randomized prospective studies as well as meta-analyses show a decrease in the number of perioperative and postoperative complications following carotid endarterectomy using patches compared with primary arterial closure. Despite the fact that the autologous vein is the material of choice for carotid patch angioplasty, xenogenic and synthetic patches are also widely used in the clinical practice. Furthermore, tissue engineering technologies and the development of novel biomaterials have recently emerged and may encourage manufacturing of vascular patches capable to promote a regenerative potential of the body and restore vascular wall tissues.

In vivo endothelialization and neointimal hyperplasia assessment after angioplasty of sheep carotid artery with a novel polycarbonate polyurethane patch.

The aim of this study was to compare two variants of a novel polycarbonate polyurethane prosthesis with polyethylene terephthalate (Dacron) prosthesis in an established sheep model of carotid patch angioplasty. Two variants of the polycarbonate polyurethane prosthesis were used: (1) Polycarbonate polyurethane equal (PCU-e) prosthesis consisted of a multilayered porous structure with equal internal and external layers; (2) Polycarbonate polyurethane with more porous inner layers (PCU-mp) prosthesis had more porous inner layers than external layers. Carotid patch angioplasty was performed in 12 sheep: in six sheep, the PCU-e variant and in the other six sheep, the PCU-mp variant was implanted. Dacron patches were implanted in the contralateral carotid artery of all sheep as a control. Half of the animals with each polycarbonate polyurethane variant were euthanized after two weeks and the other half after eight weeks. Cellular infiltration, endothelialization, and neointimal hyperplasia were examined. All grafts were patent, and no thrombus was seen in any of the harvested arteries. The pores of all the three patch materials allowed infiltration of inflammatory cells, capillaries, and connective tissue. After eight weeks, a nearly complete endothelialization was visible in all patch groups without an obvious difference between the three patch materials. The neointima was thinner in the PCU patches (PCU-e: 56 ± 13 µm, PCU-mp: 119 ± 60 µm) when compared to Dacron patches (156 ± 64 µm) after two weeks. After 8 weeks, a further neointimal growth was detectable, without any significant difference of neointimal thickness between the three patch materials (Dacron: 274 ± 82 µm, PCU-e: 324 ± 98 µm, PCU-mp: 235 ± 59 µm). With the novel polycarbonate polyurethane patch materials, we achieved promising functional and morphological results with 100% patency and nearly complete endothelialization. Our findings showed at least a non-inferiority of the novel polycarbonate polyurethane patch material compared to Dacron. There were no significant differences detected between the two polycarbonate polyurethane patch variants.

Novel methods for the mechanical characterization of patches used in carotid artery repair

Carotid endarterectomy (CEA) is one of the approaches available for the treatment of carotid artery disease, with carotid patch angioplasty the pertinent technique mostly preferred by vascular surgeons. This technique entails an arteriotomy succeeded by closure with a textile, polymer or biological tissue patch. In this work, we propose microbuckling and microindentation as novel methodologies for acquiring the mechanical properties of patches used in carotid artery repair. Regarding microbuckling, the patch is loaded by a sensitive dynamometer at one end and its motion is recorded, at three different levels of axial deformation: δ/ℓ = 0.1, 0.3 and 0.5 (in the post-buckling regime). The corresponding experimental loads are recorded, as well. Following pertinent closed-from equations, various material metrics are obtained, such as the Young's modulus of elasticity and the so-called frictional couple of the material. Regarding microindentation, the material's hardness number is measured with the aid of a durometer. Similar to microbuckling, indentation analytical expressions allow for the determination of key material properties, such as the modulus of elasticity, indentation forces and depths. Where possible, we perform microtension to verify acquired results. Results demonstrate that measured properties may vary substantially for materials which are of the same type, due to variations of the material microstructure, as observed with optical and scanning electron microscopes (SEM). Several commercial patches were tested in this work. To shortly present the main results, the microbuckling technique furnished (for the Young's modulus) 40.17 MPa for the B/Braun Aesculap cardiovascular patch and 71.49 MPa for the Vasutek Terumo, while the microindentation technique, for bovine patches, provided 6.356 MPa for the Xeno Sure and 4.701 MPa for the Vascu-Guard. A test type recommendation is provided, relating the type of the patch material to the method more plausible in each case, in order to achieve better measurement accuracy. Results of this study can contribute in establishing guidelines and criteria determining material selection in CEA.

Vein Patch Closure Using Below the Knee Greater Saphenous Vein for Femoral Endarterectomy Procedures is Not Always a Safe Choice.

BackgroundThe complication of vein patch rupture is well described after carotid patch angioplasty; however, there is a paucity of data about the safety of vein patch closure in the setting of femoral endarterectomy.Methods/resultsFrom May 2012 to May 2015, 115 femoral endarterectomies with patch closure were performed. A patch rupture occurred in three cases (2.6%) with a mortality rate of 66% (2/3). In all cases the greater saphenous vein below the knee was used as patch material.Discussion/conclusionVein patches, particularly from small calibre veins, should be excluded in femoral endarterectomy procedures as they pose a substantial risk of rupture.

In vivo xenogeneic scaffold fate is determined by residual antigenicity and extracellular matrix preservation

The immunological potential of animal-derived tissues and organs is the critical hurdle to increasing their clinical implementation. Glutaraldehyde-fixation cross-links proteins in xenogeneic tissues (e.g., bovine pericardium) to delay immune rejection, but also compromises the regenerative potential of the resultant biomaterial. Unfixed xenogeneic biomaterials in which xenoantigenicity has been ameliorated and native extracellular matrix (ECM) architecture has been maintained have the potential to overcome limitations of current clinically utilized glutaraldehyde-fixed biomaterials. The objective of this work was to determine how residual antigenicity and ECM architecture preservation modulate recipient immune and regenerative responses towards unfixed bovine pericardium (BP) ECM scaffolds. Disruption of ECM architecture during scaffold generation, with either SDS-decellularization or glutaraldehyde-fixation, stimulated recipient foreign body response and resultant fibrotic encapsulation following leporine subpannicular implantation. Conversely, BP scaffolds subjected to stepwise removal of hydrophilic and lipophilic antigens using amidosulfobetaine-14 (ASB-14) maintained native ECM architecture and thereby avoided fibrotic encapsulation. Removal of hydrophilic and lipophilic antigens significantly decreased local and systemic graft-specific, adaptive immune responses and subsequent calcification of BP scaffolds compared to scaffolds undergoing hydrophile removal only. Critically, removal of antigenic components and preservation of ECM architecture with ASB-14 promoted full-thickness recipient non-immune cellular repopulation of the BP scaffold. Further, unlike clinically utilized fixed BP, ASB-14-treated scaffolds fostered rapid intimal and medial vessel wall regeneration in a porcine carotid patch angioplasty model. This work highlights the importance of residual antigenicity and ECM architecture preservation in modulating recipient immune and regenerative responses towards xenogeneic biomaterial generation.

Editorial Comment: Do not throw away anything from the pig

Among the surgical sciences, paediatric cardiac surgery is one of the closest to the concept of reconstruction. Despite the common use of the verb ‘to recycle’ in the third millennium, this notion cannot always be applied to our field and a multitude of materials, patches and conduits have to be used, often leading to rejection, aneurysm formation, calcification and stenosis. Moreover, our population is very particular for the potential of growing inherent to the age of patients. For these reasons we are forced to use materials that can give the best results in shortterm follow-up but that cannot remain effective in the longer term. The opportunity to use living materials, growing patches or valves, opens up exciting possibilities—opens up incredible possibilities for our patients. The extracellular matrix (ECM) is the naturally-occurring bioscaffold that surrounds cells in almost all tissues and organ structures. It is an acellular biomaterial that is gradually remodelled, leaving behind organized and healthy tissue. When implanted as a patch, the ECM acts as a scaffold into which the patient’s cells migrate and integrate until it is gradually replaced. ECMs originating from various organs have been tested and good results reported. Among the types available, the CorMatrixTM patch (CorMatrix, Alpharetta, Georgia, USA), which is derived from porcine small intestinal submucosa extracellular matrix (SIS-ECM), is one of the most promising options among those commercially available. In this issue of the Journal [1], Witt and colleagues report their experience in the use of the SIS-ECM CorMatrix patch in 37 paediatric patients. Their patient population was divided into four groups, depending on the implant location: septal defect patching, vascular patching, outflow tract patching or valve reconstruction. There were four deaths (10.8%) at a follow-up time of 411 ± 225 days (range 62–757 days), with no death attributed to the implanted SIS-ECM, even though, in one patient with coronary ostial stenosis after supravalvular aortic patch enlargement, the suspicion of a relationship is legitimate. The best results were reported in the septal closure group. Unfortunately, a septal closure can be accomplished perfectly with many other cheaper materials and the potential of SIS-ECM is probably greatly reduced in this situation. In adult patients, where the extent of the patch is bigger, SIS-ECM is probably justified and could provide better results in terms of the possibility of restoring suitable cardiac muscle. In pulmonary or aortic enlargement plasty, the growth potential of SIS-ECM is interesting. In Witt’s experience [1], vascular patching accounted for more than 50% of SIS-ECM patch applications (26 locations), with just one re-operation for pulmonary artery residual stenosis. No aneurysm formation was reported when used for aortoplasty [1]. This promising experience confirms that of others. Indeed, Padalino implanted SIS-ECM patch on the abdominal aorta in 15 rats [2]. Graft re-population was demonstrated as early as 15 days after implantation, while it was almost completely remodelled 180 days after implantation. No significant graft aneurysmatic dilation or detachment was present. The new aortic wall presented with an intima incorporating an endothelial lining, a media with smooth muscle cells and an adventitia containing vessels and fibroblasts [2]. The same encouraging results were not obtained in the clinical experience by McCready, who reported seven episodes of patch aneurysm among 76 patients who had undergone patch angioplasty of the carotid artery following endoarterectomy [3]. The patch used in this latter study was another SIS-ECM product (Surgisis by Cook Surgical, Bloomington, IN, USA) that was thinner than CorMatrix. However, aneurysmal dilation of the graft patch has been described when the CorMatrix was used in carotid patch angioplasty. As regards right ventricular outflow tract (RVOT) reconstruction, Witt reported on six patients with one re-operation. In three patients, a unicusp SIS-ECM valve was created but, unfortunately, one patient died from low cardiac output and the other two showed moderate-to-severe valve incompetence. School reported four unicusp valves implanted in pulmonary outflow tract reconstruction with three of them competent at an average follow-up of 9 months: too short to be of significance [4]. Quarti reported 26 cases treated with SIS-ECM patch reconstruction, nine of which were cusp extension valvular repairs: five aortic, two tricuspid, one mitral and one pulmonary valve. At a mean follow-up of 12.5 months no patients had undergone re-operation and no more than mild incompetence was evident [5]. A large variability of results is evident among all the reported experiences. An interesting experimental study by Tottey confirms that differences exist in the composition, structure and

Radiosurgical Dose Selection for Secreting Pituitary Adenomas

Although the healing response after carotid balloon injury and carotid patch angioplasty injury has been well-documented in animal models, there is limited information about this process after carotid endarterectomy (CEA) in human patients.We describe the autopsy results of a 79-year-old man who died 18 days after CEA with patch angioplasty. The treated carotid artery had an adequate luminal diameter. Elastica-Masson staining revealed that the treated portion was covered with neointima but the patch graft was exposed to the arterial lumen at 18 days after CEA. Immunohistochemistry staining for alpha-smooth muscle actin (α-SMA), von-Willebrand factor, and vascular endothelial growth factor receptor-2 revealed that the neointima was mainly composed of α-SMA-positive cells. In addition, the α-SMA-rich neointima had many more Ki-67-positive cells than did the internal carotid artery intima in the area beyond the CEA-treated portion.This case report is the first to describe an entire carotid artery specimen in the acute stage after CEA with patch angioplasty. These findings suggest that an α-SMA-rich neointima with prominent proliferative activity covers the inner surface of the treated carotid artery, but patch grafts are left uncovered. The intrinsic arterial wall may have an important role in intimal regeneration after CEA, although the nature of the neointima and the mechanism by which it regulates proliferative activity remain unclarified.

Systematic Review of Randomized Controlled Trials of Different Types of Patch Materials during Carotid Endarterectomy

Background and PurposeCarotid endarterectomy (CEA) with patch angioplasty produces greater results than with primary closure; however, there remains uncertainty on the optimal patch material in CEA. A systematic review of randomized controlled trials (RCTs) was performed to evaluate the effect of angioplasty using venous patch versus synthetic patch material, and Dacron patch versus polytetrafluoroethelene (PTFE) patch material during CEA.MethodsA multiple electronic health database screening was performed including the Cochrane library, Pubmed, Ovid, EMBASE and Google Scholar on all randomized controlled trials (RCTs) published before November 2012 that compared the outcomes of patients undergoing CEA with venous patch versus synthetic patch. RCTs were included if they compared carotid patch angioplasty with autologus venous patch versus synthetic patch material, or compared one type of synthetic patch with another.ResultsThirteen RCTs were identified. Ten trials, involving 1946 CEAs, compared venous patch with synthetic patch materials. Two trials, involving 400 CEAs in 380 patients, compared Dacron patch with PTFE patch. The hemostasis time in CEA with PTFE patch was significantly longer than with venous patch (P<0.0001), and longer than with Dacron patch (P<0.0001). There was no significant difference of mortality rate, stroke rate, restenosis, and operative time in CEA with venous patch versus synthetic patch material, or in CEA with Dacron patch versus PTFE patch (all P>0.05). One RCT of 95 CEAs in 92 patients compared bovine pericardium with Dacron patch, and demonstrated a statistically significant decrease in intraoperative suture line bleeding with bovine pericardium compared with Dacron patch (P<0.001).ConclusionsThe hemostasis time in CEA with PTFE patch was longer than with venous patch or Dacron patch. The overall perioperative and long-term mortality rate, stroke rate, restenosis, and operative time were similar when using venous patch versus synthetic patch material or Dacron patch versus PTFE patch material during CEA. More data are required to clarify differences between different patch materials.

Case-matched Comparison of Early and Long-term Outcomes of Everted Cervical Vein and Saphenous Vein Carotid Patch Angioplasty

Objectives To compare outcomes after carotid endarterectomy (CEA) with saphenous vein patch closure (SV), with cervical vein (external jugular and common facial) patch closure (CV). Design A total of 322 cases of CEA was achieved consecutively by using venous patch angioplasty. Propensity scores were calculated followed by a one-to-one basis case-matching. Materials This resulted into 90 SV and 90 CV matched cases. Methods The primary endpoint was the incidence of ipsilateral stroke and transient ischaemic attack at any time during follow-up. Results Ten-year freedom from stroke was 94.1% ± 3.5% for the SV group and 90.5% ± 4.2% for the CV group (log rank P = 0.230). Ten-year freedom from ipsilateral neurological events (stroke and transient ischaemic attack) was 93.5% ± 3.3% for SV group and 92.4% ± 3.0% for the CV group (log rank P = 0.403). Ten-year freedom from ≥75% stenosis/occlusion was 93.1 ± 4.8% for the SV group and 89.9 ± 6.0% for the CV group (log rank P = 0.481). Conclusions CV is a good alternative to SV patching, particularly when the SV needs to be preserved for further use or is unsuitable.

Systematic Review of Randomized Controlled Trials of Patch Angioplasty Versus Primary Closure and Different Types of Patch Materials During Carotid Endarterectomy

Patch angioplasty during carotid endarterectomy (CEA) can reduce the risk of perioperative stroke or late carotid artery recurrent stenosis and subsequent ischaemic stroke. We aimed to update our previous systematic review of randomized controlled trials (RCTs) of routine or selective carotid patch angioplasty compared with CEA with primary closure, and of different materials used for carotid patch angioplasty. We identified new RCTs published during 2002-2010 by searching Medline, Embase and the Cochrane Stroke Group Trials Register. We also hand-searched six relevant journals. Pooled estimates of treatment effects combined with our previous review (1966-2001) were calculated on the basis of a weighted estimate of the odds ratio (OR) with the Peto method. Twenty-three eligible RCTs were identified in both periods. Ten RCTs involving 2,157 operations compared primary closure with routine patch closure. Patch closure significantly reduced the combined risk of perioperative stroke and later stroke during long-term follow-up [OR = 0.49, 95% confidence interval (CI) = 0.27-0.90, p = 0.001; 7 RCTs]. Patching also reduced the risks of perioperative arterial occlusion (OR = 0.18, 95% CI = 0.08-0.41, p < 0.0001; 7 RCTs) and recurrent stenosis during long-term followup (OR = 0.24, 95% CI = 0.17-0.34, p < 0.001; 8 RCTs). Meta-analysis of relatively small RCTs suggests that carotid patch angioplasty reduces the combined perioperative and long-term risk of stroke and the risk of restenosis. More data are needed.

PS80. Systematic Review of Randomized Controlled Trials of Patch Angioplasty Versus Primary Closure and Different Types of Patch Materials During Carotid Endarterectomy

Patch angioplasty during carotid endarterectomy (CEA) may reduce the risk for perioperative or late carotid artery recurrent stenosis and subsequent ischemic stroke. We performed a systematic review of randomized controlled trials to assess the effect of routine or selective carotid patch angioplasty compared with CEA with primary closure, and the effect of different materials used for carotid patch angioplasty. Randomized trials during 1966-2009 were included if they compared carotid patch angioplasty with primary closure in any patients undergoing CEA or use of one type of carotid patch with another. Twenty-three eligible randomized trials were identified. Ten trials involving 2157 operations compared primary closure with routine patch closure, and thirteen trials with 2083 operations compared different patch materials. Patch angioplasty was associated with a reduction in risk for ipsilateral stroke during the perioperative period (p = 0.001), and long-term follow-up (p = 0.001). Patching was also associated with reduced risk for perioperative arterial occlusion (P <.0001) and decreased recurrent stenosis during long-term follow-up (p < 0.001). Seven trials that compared between vein and synthetic patches showed that apart from psudoanaeurysmal formation, there were no significant different in the outcome between vein patch and synthetic materials in either the short- or long-term. There were significantly fewer pseudoaneurysms associated with synthetic patches than vein patches (p = 0.005) Carotid patch angioplasty decreases the risk for both ipsilateral stroke in both perioperative and long-term risk. More data are required to establish differences between various patch materials.

Patches of different types for carotid patch angioplasty

Carotid patches for carotid endarterectomy may be made from an autologous vein or synthetic material. To assess the safety and efficacy of different materials for carotid patch angioplasty. We searched the Cochrane Stroke Group trials register (last searched 3 August 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2009), MEDLINE (1966 to November 2008), EMBASE (1980 to November 2008) and Index to Scientific and Technical Proceedings (1980 to 2008). We handsearched relevant journals and conference proceedings, checked reference lists, and contacted experts in the field. Randomised and quasi-randomised trials comparing one type of carotid patch with another for carotid endarterectomy. Two review authors independently assessed eligibility, trial quality, and extracted data. We included 13 trials involving a total of 2083 operations; seven trials compared vein closure with PTFE closure, and six compared Dacron grafts with other synthetic materials. In most trials a patient could be randomised twice and have each carotid artery randomised to different treatment groups. There were no significant differences in the outcomes between vein patches and synthetic materials apart from pseudoaneurysms where there were fewer associated with synthetic patches than vein patches (odds ratio (OR) 0.09, 95% confidence interval (CI) 0.02 to 0.49). However, the numbers involved were small and the clinical significance of this finding is uncertain. Compared to other synthetic patches, Dacron was associated with a higher risk of: perioperative combined stroke and transient ischaemic attack (P = 0.03); restenosis at 30 days (P = 0.004); perioperative stroke (P = 0.07) and perioperative carotid thrombosis (P = 0.1). During follow-up for more than one year, there were also significantly more strokes (P = 0.03), stroke/death (P = 0.02) and arterial restenoses (P < 0.0001) with Dacron but the numbers of outcomes were small and the significance of this finding is uncertain. The number of outcome events is too small to allow reliable conclusions to be drawn and more trial data are required to establish whether any differences do exist. Nevertheless, there is some evidence that other synthetic (e.g. PTFE) patches may be superior to collagen impregnated Dacron grafts in terms of perioperative stroke rates and restenosis. Pseudoaneurysm formation may be more common after use of a vein patch compared with a synthetic patch.

Patch angioplasty versus primary closure for carotid endarterectomy

Carotid patch angioplasty (with either a venous or a synthetic patch) may reduce the risk of carotid artery restenosis and subsequent ischaemic stroke. This is an update of a Cochrane Review originally published in 1995 and previously updated in 2004. To assess the safety and efficacy of routine or selective carotid patch angioplasty compared to carotid endarterectomy with primary closure. We searched the Cochrane Stroke Group Trials Register (last searched 5 May 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2009), MEDLINE (1966 to November 2008), EMBASE (1980 to November 2008) and Index to Scientific and Technical Proceedings (1980 to November 2008). We handsearched journals and conference proceedings, checked reference lists, and contacted experts in the field. Randomised and quasi-randomised trials comparing carotid patch angioplasty with primary closure in any patients undergoing carotid endarterectomy. Two review authors independently assessed eligibility, trial quality and extracted data. We included 10 trials involving 1967 patients undergoing 2157 operations. The quality of trials was generally poor. Follow up varied from hospital discharge to five years. Carotid patch angioplasty was associated with a reduction in the risk of ipsilateral stroke during the perioperative period (odds ratio (OR) 0.31, 95% confidence interval (CI) 0.15 to 0.63, P = 0.001) and long-term follow up (OR 0.32, 95%CI 0.16 to 0.63, P = 0.001). It was also associated with a reduced risk of perioperative arterial occlusion (OR 0.18, 95% CI 0.08 to 0.41, P < 0.0001), and decreased restenosis during long-term follow up in eight trials (OR 0.24, 95% CI 0.17 to 0.34, P < 0.00001). These results are more certain than those of the previous review since the number of operations and events have increased. However, the sample sizes are still relatively small, data were not available from all trials, and there was significant loss to follow up. Very few arterial complications, including haemorrhage, infection, cranial nerve palsies and pseudo-aneurysm formation were recorded with either patch or primary closure. No significant correlation was found between use of patch angioplasty and the risk of either perioperative or long-term all-cause death rates. Limited evidence suggests that carotid patch angioplasty may reduce the risk of perioperative arterial occlusion and restenosis. It would appear to reduce the risk of ipsilateral stroke and there is a non significant trend towards a reduction in perioperative any stroke rate and all-cause case fatality.

Clinical analysis of microsurgical carotid endarterectomy for carotid stenosis and occlusion

To evaluate the clinical effects of carotid endarterectomy for carotid stenosis and occlusion. From August 2005 to November 2008 moderate and severe carotid stenosis or occlusion were found in 16 patients by Doppler ultrasonography (DUS), MRA, CTA, DSA. The stenosis degree ranged from 60% to 99% in 14 patients and complete occlusion in 2 patients. Twelve patients underwent standard carotid endarterectomy (sCEA) in whom 2 patients were placed carotid shunt and 1 patient underwent carotid patch angioplasty. Four patients underwent eversion carotid endarterectomy (eCEA). All operations were performed by microscope. There was no stroke, transient ischemic attack and mortality perioperatively and during follow-up from 1 month to 3 years. The ICA flow detected by follow-up duplex scan and MRA was unobstructed. The primary cerebral ischemic symptoms were obviously improved or disappeared after operation. The postoperative complications included one case of upper gastrointestinal hemorrhage and one case of hoarseness and bucking, which disappeared after medical treatment. CEA is an effective way for treating carotid stenosis. Different operative methods and techniques deal with different carotid lesions to achieve better effect. Microsurgical technique is useful for exposure of high ICA bifurcation and avoid effectively cranial nerve injury and other complications.

ESVS Guidelines. Invasive Treatment for Carotid Stenosis: Indications, Techniques

The European Society for Vascular Surgery brought together a group of experts in the field of carotid artery disease to produce updated guidelines for the invasive treatment of carotid disease. The recommendations were rated according to the level of evidence. Carotid endarterectomy (CEA) is recommended in symptomatic patients with >50% stenosis if the perioperative stroke/death rate is <6% [A], preferably within 2 weeks of the patient's last symptoms [A]. CEA is also recommended in asymptomatic men <75 years old with 70-99% stenosis if the perioperative stroke/death risk is <3% [A]. The benefit from CEA in asymptomatic women is significantly less than in men [A]. CEA should therefore be considered only in younger, fit women [A]. Carotid patch angioplasty is preferable to primary closure [A]. Aspirin at a dose of 75-325 mg daily and statins should be given before, during and following CEA. [A] Carotid artery stenting (CAS) should be performed only in high-risk for CEA patients, in high-volume centres with documented low peri-operative stroke and death rates or inside a randomized controlled trial [C]. CAS should be performed under dual antiplatelet treatment with aspirin and clopidogrel [A]. Carotid protection devices are probably of benefit [C].

Discretionary carotid patch angioplasty leads to good results

Background This study evaluated the type and need for angioplasty in 253 consecutive carotid endarterectomies. Methods Polyester knitted gelatin sealed patch (DP) and polytetrafluoroethylene (PTFE) patches were used in, respectively, 159 and 29 patients, with 65 vessels closed primarily (no patch [NP]). Results Surgical results, estimated blood loss, and surgical time were similar in each group. Postoperative hematomas occurred in 6 DP and 3 NP patients. There were 3 strokes in the DP group. Long-term duplex evaluation was possible in 201 patients. The number of patients who had less than 15%, 15% to 50%, 50% to 79%, 80% to 99%, 100%, or an ungraded degree of narrowing were as follows for each group: DP, 117, 2, 5, 0, 1, and 2; PTFE, 18, 1, 1, 0, 0; and NP, 53, 0, 0, 0, 1. Statistical analysis failed to show any difference between groups postoperatively or in long-term follow-up evaluation. Conclusions It appears that selective patching is safe and effective in male patients who undergo carotid endarterectomy. The type of patch material also is inconsequential. Patch type and its use should be at the surgeon’s discretion.