Classical Carotid Endarterectomy Research Articles

Invited commentary

Preoperative planning for an interposition carotid bypass graft in patients undergoing carotid endarterectomy (CEA) is rare except in the case of known infection. However, in 1% to 3% of primary CEAs and in a higher rate of reoperative carotid procedures, a carotid bypass graft is the simplest and possibly the safest reconstruction technique. It should be in the repertoire of every surgeon undertaking CEA. The Camiade and Lauder articles are important because they demonstrate, first, that carotid bypass grafts have excellent outcomes considering that they are frequently used in adverse conditions; second, that a number of geometric configurations are possible depending on and tailored to operative findings; and, third, that both polytetrafluoroethylene (PTFE) and greater saphenous vein are acceptable conduits. The indications for consideration of carotid bypass include infection, extensive long-segment atheroma in the common and/or internal carotid arteries, kinking or coiling of the internal carotid, severely damaged endarterectomized surfaces, stenosis after neck radiation, restenosis after CEA or angioplasty, and stenting and intraoperative and early postoperative technical defects or thrombosis after classical CEA reconstruction. It is generally agreed that the most hemodynamically sound bypass is a tapered end-to-end common to the internal carotid conduit excluding the external carotid origin. One way of constructing this with saphenous vein is shown in Figure 2, B of Lauder et al. The most anatomically correct geometry is given in Figure 2, C, a beveled end-to-end bypass graft that begins at the internal carotid origin and preserves the external carotid. The absence of a carotid bulb in this reconstruction is probably hemodynamically advantageous. However, there are situations in both primary and reoperative carotid surgery where end-to-side proximal and/or distal anastomoses are the simplest and safest courses with limited or perhaps no exposure of the bifurcation segment. Several of these techniques are illustrated in these two articles. Since the advisability and, at times, necessity of carotid bypass reconstruction is most often recognized at operation, harvesting of a greater saphenous vein is cumbersome at best unless a thigh and groin have been prepped and draped. The good news in the article by Camiade et al is the excellent early and long-term outcomes with PTFE bypass grafts. In contrast, the downside of the results of Naylor et al is the relatively high incidence of early saphenous vein graft stenosis. Postoperative surveillance is advisable for both PTFE and saphenous vein bypass grafts. Finally, although there are a few reports of successful CEA after carotid angioplasty and stenting restenosis, stent perforation through the adventitia will likely necessitate interposition bypassing. These two articles give confidence in and credibility for interposition bypass as an acceptable alternative method of carotid reconstruction.