Eversion Endarterectomy Research Articles

Eversion endarterectomy from common femoral artery bifurcation

Common femoral artery (CFA) bifurcation is a critical arterial segment of the lower extremities. Dos Santos J.C. first described endarterectomy from CFA in 1946. It is still preferable method for many patients with occlusion of CFA bifurcation. Although this technique is common in carotid artery surgery and much less common for atherosclerotic lesion of CFA bifurcation, some authors describe favorable results after eversion endarterectomy. Eversion endarterectomy is preferable if synthetic material and autologous veins are unavailable for repair.

Abstract 252: The outcomes and complications in patients undergoing subclavian‐carotid artery bypass surgery: A case series

Introduction Endovascular intervention has become the mainstay of treatment for acute ischemic stroke. However, in certain cases, open surgery is the only option to achieve revascularization. This study presented two patients with symptomatic common carotid artery occlusion (CCAO) who subsequently underwent subclavian‐carotid artery bypass surgery using the polytetrafluorethylene graft. The complications of the procedure and patient’s outcomes were discussed. Methods We identified two patients who were admitted to our medical center between January 2022 to December 2022 for subclavian‐carotid artery bypass procedure. Clinical data were reviewed retrospectively. Results Case 1. A 69‐year‐old woman with a history of lung cancer, hypertension, chronic tobacco use, atherosclerosis, and known calcified plaque at the left carotid bifurcation on dual antiplatelet therapy presented with acute onset of expressive aphasia and right hemiparesis due to acute left CCAO. Endovascular procedure was deferred due to difficult arterial access. An endarterectomy of CCA, eversion endarterectomy of external carotid artery, and subclavian‐carotid artery bypass surgery were performed. She developed neck hematoma post‐operatively, requiring evacuation. She was discharged to acute rehabilitation facility and eventually home. Six months after surgery, she still had severe expressive aphasia and spasticity of the right arm and leg (Figure A‐C). Case 2. A 79‐year‐old man with a strong family history of arterial dissection, hypertension, coronary artery disease, and obesity experienced intense chest pain and left hemiparesis secondary to Type A aortic dissection with extension from the innominate artery to the right carotid bifurcation. Endovascular intervention was deferred given the angulation of aortic arch after surgical repair. Decision was made to perform subclavian‐carotid artery bypass surgery. Post‐operatively, he had evacuation of neck hematoma. He also had tracheostomy and gastrostomy tube placement prior to discharge to skilled nursing facility. At 6‐month follow up, he could ambulate with a walker and oral diet was resumed (Figure D‐F). Conclusion CCAO is a rare condition, and there is no prospective randomized trial that compares various treatment strategies for symptomatic CCAO. Consistent with the findings of our study, bypass surgeries have been shown as an effective treatment to prevent further ischemic infarct in patients with symptomatic CCAO. Both patients in our study survived at 6‐month follow up with no recurrence of stroke. Additionally, no other surgical complications were noted except for neck hematoma. Bypass surgery was performed as a salvage procedure for both patients after they suffered from stroke. Early identification of CCAO and collaboration between vascular surgeon and endovascular interventionist would maximize the benefit of this life‐saving procedure to the appropriate candidates.

Assessment of cerebral autoregulatory function and inter-hemispheric blood flow in older adults with internal carotid artery stenosis using transcranial Doppler sonography-based measurement of transient hyperemic response after carotid artery compression

Unhealthy vascular aging promotes atherogenesis, which may lead to significant internal carotid artery stenosis (CAS) in 5 to 7.5% of older adults. The pathogenic factors that promote accelerated vascular aging and CAS also affect the downstream portion of the cerebral microcirculation in these patients. Primary treatments of significant CAS are eversion endarterectomy or endarterectomy with patch plasty. Factors that determine adequate hemodynamic compensation and thereby the clinical consequences of CAS as well as medical and surgical complications of carotid reconstruction surgery likely involve the anatomy of the circle of Willis (CoW), the magnitude of compensatory inter-hemispheric blood flow, and the effectiveness of cerebral microcirculatory blood flow autoregulation. This study aimed to test two hypotheses based on this theory. First, we hypothesized that patients with symptomatic and asymptomatic CAS would exhibit differences in autoregulatory function and inter-hemispheric blood flow. Second, we predicted that anatomically compromised CoW would associate with impaired inter-hemispheric blood flow compensation. We enrolled older adults with symptomatic or asymptomatic internal CAS (>70% NASCET criteria; n = 46) and assessed CoW integrity by CT angiography. We evaluated transient hyperemic responses in the middle cerebral arteries (MCA) after common carotid artery compression (CCC; 10 s) by transcranial Doppler sonography (TCD). We compared parameters reflecting autoregulatory function (e.g., transient hyperemic response ratio [THRR], return to baseline time [RTB], changes of vascular resistance) and inter-hemispheric blood flow (residual blood flow velocity). Our findings revealed that CAS was associated with impaired cerebral vascular reactivity. However, we did not observe significant differences in autoregulatory function or inter-hemispheric blood flow between patients with symptomatic and asymptomatic CAS. Moreover, anatomically compromised CoW did not significantly affect these parameters. Notably, we observed an inverse correlation between RTB and THRR, and 49% of CAS patients exhibited a delayed THRR, which associated with decreased inter-hemispheric blood flow. Future studies should investigate how TCD-based evaluation of autoregulatory function and inter-hemispheric blood flow can be used to optimize surgical techniques and patient selection for internal carotid artery revascularization.

Feasibility of patchless proximal profundoplasty and common femoral endarterectomy.

Typical repair of common femoral artery (CFA) occlusive disease involves surgical endarterectomy followed by patch closure; however, prosthetic materials may become infected. In addition, in our institution, we have experienced an increased incidence of severe patch-related restenosis. We describe a technique for CFA endarterectomy and patchless proximal profundoplasty, and evaluate its feasibility. We performed a single-centre retrospective cohort study of patients who, between July 1, 2020, and June 30, 2021, underwent a procedure that consisted of transection of the superficial femoral artery (SFA) off the femoral bifurcation in a bevelled manner, eversion endarterectomy of the SFA, remote-type endarterectomy of the CFA, direct visualization of the end point in the profunda femoris artery (PFA) with a longitudinal arteriotomy extension if needed and reimplantation of the SFA "hood" as a patch. We collected clinical information and outcomes from the patients' charts. Ten patients who underwent a patchless profundoplasty procedure during the study period were identified. Indications for repair included tissue loss (3 patients), rest pain (2 patients), claudication (3 patients) and establishing access for other procedures (2 patients). Profunda femoris artery arteriotomy extensions were used in 5 cases. Six cases included simultaneous iliac or infrainguinal revascularization. All cases were technically successful. There was 1 intraoperative complication of remote tibial balloon angioplasty tear. The mean follow-up time was 199 (range 29-381) days. There were no surgical site infections. All patients were asymptomatic, with patent CFAs, at last follow-up. There was 1 case of surgical site restenosis and 1 reintervention for remote stenosis. The average increase in ankle and toe brachial indices was 44% and 75%, respectively. One patient was readmitted for gastrointestinal bleeding. One patient died from an acute myocardial infarction, on postoperative day 34. The patchless profundoplasty technique is feasible and results in autologous anatomic repair of CFA disease without the need for vein, and allows direct visualization and tacking sutures of the proximal PFA. This technique may replace the ubiquitous vascular procedure of patch arterioplasty of the CFA, depending on the anatomic configuration.

Routine versus selective near-infrared spectroscopy-guided shunting during carotid eversion endarterectomy.

The aim of this study was to compare outcomes of routine shunting to near-infrared spectroscopy (NIRS)-guided shunting in patients undergoing eversion endarterectomy (EEA) under general anaesthesia. We retrospectively evaluated data of all patients undergoing EEA of the internal carotid artery (ICA) in our department from January 2011 until January 2019. Included were patients with EEA of the ICA and the patients were divided into 2 groups: selective-shunting group and routine-shunting group. Patients (i) with patch angioplasty during the surgery, (ii) undergoing surgery for restenosis and (ii) stenosis after radiation therapy, (iii) without recorded regional cerebral oxygen saturation trends, (iv) presenting with an emergency treatment indication and (v) operated upon by residents were excluded. In all patients, EEA was performed in general anaesthesia and under NIRS monitoring. One-to-one propensity score matching was used to compare EEA outcomes after routine shunting to NIRS-guided shunting. Primary end points were defined as perioperative stroke and in-hospital mortality after EEA. Routine and NIRS-guided selective shunting were applied in 340 (34.0%) and 661 (66.0%) patients, respectively. A total of 277 pairs were generated via propensity score matching. Fifty-eight (20.1%) from the selective-shunting group were intraoperatively shunted. Concomitant procedures were more frequently performed in the routine-shunting group [170 (61.4%) vs 47 (17.0%), 180 (65%) vs 101 (36.5%), and 60 (21.7%) vs 6 (2.2%), P < 0.001]. The perioperative stroke rate in the routine-shunting group was higher as well [11 (4.0%) vs 3 (1.1%), P = 0.022]. In-hospital death was overall 0.2% (n = 1). Multivariable logistic regression in the matched patient indicated age (odds ratio 1.050, 95% confidence interval 1.002-1.104, P = 0.046) and routine shunting (odds ratio 2.788, confidence interval 1.119-7.428, P = 0.032) as risk factors for perioperative stroke during EEA of the ICA. We found that, during EEA of the ICA, under general anaesthesia, NIRS-guided selective shunting was associated with a lower incidence of perioperative stroke than routine shunting.

The Impact of Revascularization in a Patient with Atypical Manifestations of Hypoperfusion

Background and Objectives: Carotid revascularization is one of the most effective treatment options in patients with severe carotid artery stenosis causing hypoperfusion in basal ganglia. Atypical manifestations include hyperkinetic movements, noted as extremely rare. We report a case about a patient with 2-months-long complaints of Uncontrollable movements in his right side of the body subsided after carotid revascularization. Case presentation: A 71-year-old male was admitted to Pauls Stradins Clinical University Hospital with the main complaints of 2-months-long uncontrollable movements in his right hand and his right leg. When performing coordination tasks, slight inaccuracy was noted with the right-side extremities. Hyperkinetic movements—choreoathetosis in the right side of the patient’s face, arm, and leg—were seen. Computed tomography angiography revealed subocclusion in the proximal segment of the left internal carotid artery and 30% stenosis in the proximal segment of the right internal carotid artery. The patient was consulted by a vascular surgeon. Eversion endarterectomy of the left internal carotid artery was performed. The early postoperative period occurred without complications. The patient was discharged from the hospital 2 days after the surgery in good overall health condition. Two months later, choreoathetotic movements in his right side of the body had markedly decreased. No focal neurologic deficits were noted. Conclusions: Revascularization may be effective by eliminating emboli and stenosis, leading to hypoperfusion in watershed territories. A case of a 71-year-old male patient with the main complaints of 2-months-long uncontrollable movements in his right side of the body subsiding after carotid revascularization was demonstrated. It is vital to recognize atypical manifestations of hypoperfusion, associated with stenosis in internal carotid arteries, to early make a diagnosis, to perform an appropriate treatment, and to reduce the risk of cerebral infarction in the future, resulting in a longer high-quality life for the patient.

Risk Factors for Carotid Restenosis in Patients After Eversion Endarterectomy vs Stenting: A Single-Center Experience.

The primary aim of the presented study is to analyze and compare the rate of carotid restenosis in patients after eversion carotid endarterectomy (eCEA), primary carotid angioplasty and stenting (CASp), and stenting for carotid artery restenosis after previous eCEA (CASr). The secondary aim is to compare clinical outcomes in patients with carotid restenosis. The total number of patients with evident carotid restenosis was 223 (24.8%). In patients with eCEA, significant carotid restenosis rate was 12.7%, in the CASp group 18.7%, and CASr 6.7%. Patients with carotid restenosis were asymptomatic in 95.1% of cases. Patients in the CASp group experienced transient ischemic attack more than patients with eCEA (P = .007), while no difference was observed regarding cerebrovascular insult (CVI). The incidence of carotid restenosis was higher in CASp patients, and increased during the follow-up. The majority of patients are asymptomatic post-procedural and the degree of carotid restenosis does not correlate with the occurrence of postoperative symptoms. High low-density lipoprotein cholesterol (LDL-C) levels, low high-density lipoprotein cholesterol (HDL-C) levels, smoking, and a history of vascular surgery correlate with higher degrees of carotid restenosis. The most important factor in the prevention of carotid restenosis is risk factor control as well as adequate pharmacological therapy.

Eversion endarterectomy of a segmental occlusion of internal carotid artery patent due to an aberrant ascending pharyngeal artery: A case report

Type II segmental internal carotid artery (ICA) occlusion has been described by Kniemeyer et al1 as total occlusion of the ICA at the carotid bifurcation with delayed orthograde filling through atypical collateral vessels of the proximal ICA. We present a rare case of segmental ICA occlusion with an aberrant ascending pharyngeal artery (APA) that maintains the patency of the distal ICA.

The predictive value of internal carotid artery wall thickness in computed tomography angiography to avoid complications of plaque removal failure in modified eversion carotid endarterectomy.

The benefits of computed tomography carotid angiography (CTA) in terms of evaluating the anatomical structure of the carotid arteries, surgical planning, and evaluating possible risks were reported in previous studies. This study aimed to calculate the predictive value of internal carotid wall thickness in CTA that can predict whether a modified carotid eversion endarterectomy (MCEE) will result in a successful or not. This study was designed in a retrospective cross-sectional format. Consecutive 83 symptomatic carotid surgery patients who were operated in our hospital and had CTA were included in this study. The wall thickness of the internal carotid artery (ICA) 20mm distal from the carotid bifurcation was calculated in axial sections using a three-dimensional imaging technique. In addition, all patients' characteristics and laboratory findings were recorded. Patients who failed MCEE and required classical carotid endarterectomy were compared with patients who had successful MCEE. MCEE technique was applied to 62 patients. In 21 patients, the MCEE technique failed and the classical endarterectomy technique was required. Preoperative clinical and laboratory characteristics were similar in both groups. The mean ICA wall thickness was 0.65mm 20mm distal to from the carotid bifurcation and it was lower in the group with successful MCEE (1.03 ± 0.21mm vs. 0.56 ± 0.08mm) (p < 0.001). The critical ICA wall thickness was calculated as 0.76mm in the group that MCEE failed and classical carotid endarterectomy was required. Cut-off analysis of ICA wall thickness was calculated as 0.755mm in ROC analysis (p < 0.001), (95% confidence interval, curve area; 0.985). Successful carotid endarterectomy with the MCEE method is associated with distal ICA wall thickness and distal extension of the atheroma plate. The use of ICA wall thickness 20mm distal to from the bifurcation as a predictive value for the success of the MCEE technique is beneficial to avoid serious complications.

Eversion Endarterectomy – An Alternative Approach to Occlusive External Iliac Artery disease

While endovascular intervention is the recommended first option for management of common iliac artery (CIA) lesions, it lacks durable patency for Trans-Atlantic Inter-Society Consensus (TASC)-II C and D lesions involving the external iliac artery (EIA). Aorto-femoral bypass is a durable option but is unsuitable in patients with significant co-morbidities. Eversion endarterectomy provides an alternative to both endovascular and extensive open aortoiliac reconstruction for occlusive EIA disease. A single-center, retrospective review (2000-2020) of all patients undergoing eversion endarterectomy for EIA disease was undertaken. Demographic, clinical, operative and follow-up data were recorded. Fifty eversion endarterectomies were performed in 47 patients. The median age was 65.0 years (range 46-82) and 66.6% were male. Sixty-eight percent (n=34) were ASA grade 3. Indications for intervention were disabling claudication (44%) and critical limb ischaemia (56%). Angiography demonstrated 22 TASC C and 28 TASC D lesions. The median follow-up was 18.5 months (range 0-149). The technical success rate was 100%, and 84% (n=42) experienced an immediate symptomatic improvement. Primary and primary-assisted patency at one, three and five years was 86%, 82% and 74%, and 100%, 96% and 92%, respectively. The five-year limb salvage rate was 96%. Eight limbs required reintervention to maintain patency, either by open (n=2), endovascular (n=3) or hybrid approach (n=3). Thirty-day mortality was 2% (n=1) with 10% (n=5) experiencing a procedure-related morbidity. All-cause mortality was 38% (n=19) during the follow-up period. Eversion endarterectomy is a safe, effective alternative treatment for occlusive EIA disease. This study reports durable patency at five years and low perioperative morbidity and mortality.

Influence of Eversion Endarterectomy and Patch Reconstruction on Postoperative Blood Pressure After Carotid Surgery

Post carotid blood pressure fluctuation and hypertension (PEH) are associated with increased risk for adverse outcome; there is limited evidence on the impact of eversion endarterectomy (E-CEA) versus conventional endarterectomy with patch closure (C-CEA) on postoperative blood pressure course. In this retrospective observational study, 859 consecutive carotid endarterectomy procedures between 2004 and 2014 (C-CEA n=585 vs. E-CEA n=274), were evaluated. Pre- and postoperative blood pressure values were recorded from recovery room until third postoperative day and compared between both techniques; influences on the dichotomous target variable "at least one postoperative blood pressure peak", that is need for postoperative vasodilators, were analyzed by a logistic regression model. Influences on postoperative systolic blood pressure were evaluated by a linear mixed effects regression model. Preoperative baseline blood pressure was not different between both comparison groups. During postoperative course, significantly increased mean systolic blood pressure values in the E-CEA group from recovery room to second postoperative day (recovery room C-CEA: 129.2 mm Hg vs. E-CEA: 136.5 mm Hg; P < 0.001; first postoperative day C-CEA: 132.4 mm Hg vs. E-CEA: 139.3 mm Hg; P=0.0002; second postoperative day C-CEA: 138.6 mm Hg vs. E-CEA: 143.1 mm Hg; P=0.023) were observed. No hyperperfusion syndrome was detected as wells as no difference in postoperative complication rate. Frequency of antihypertensive interventions was also elevated in E-CEA group (C-CEA 22.1 % vs. E-CEA 31.8 %; P=0.003). E-CEA (OR 1.591, 95% CI [1.146; 2.202]; P=0.005) and presence of preoperatively elevated systolic readings (OR 1.015, 95%CI [1.006;1.024]; P < 0.001) was also associated with increased need for antihypertensive interventions. E-CEA was associated with significantly elevated postoperative blood pressure, compared to C-CEA. C-CEA was associated with postoperative blood pressure decrease; however, no difference as to neurologic and surgical complications was detected between both surgical techniques in clinical practice.

Long Term Restenosis Rate After Carotid Endarterectomy: Comparison of Three Surgical Techniques and Intra-Operative Shunt Use

Closure of the artery during carotid endarterectomy (CEA) can be done with or without a patch, or performed with the eversion technique, while the use of intra-operative shunts is optional. The influence of these techniques on subsequent restenosis is uncertain. Long term carotid restenosis rates and risk of future ipsilateral stroke with these techniques were compared. Patients who underwent CEA in the International Carotid Stenting Study were divided into patch angioplasty, primary closure, or eversion endarterectomy. Intra-operative shunt use was reported. Carotid duplex ultrasound was performed at each follow up. Primary outcomes were restenosis of ≥ 50% and ≥ 70%, and ipsilateral stroke after the procedure to the end of follow up. In total, 790 CEA patients had restenosis data at one and five years. Altogether, 511 (64.7%) had patch angioplasty, 232 (29.4%) primary closure, and 47 (5.9%) eversion endarterectomy. The cumulative incidence of ≥ 50% restenosis at one year was 18.9%, 26.1%, and 17.7%, respectively, and at five years it was 25.9%, 37.2%, and 30.0%, respectively. There was no difference in risk between the eversion and patch angioplasty group (hazard ratio [HR] 0.90, 95% confidence interval [CI] 0.45 - 1.81; p= .77). Primary closure had a higher risk of restenosis than patch angioplasty (HR 1.45, 95% CI 1.06 - 1.98; p= .019). The cumulative incidence of ≥ 70% restenosis did not differ between primary closure and patch angioplasty (12.1% vs. 7.1%, HR 1.59, 95% CI 0.88 - 2.89; p= .12) or between patch angioplasty and eversion endarterectomy (4.7%, HR 0.45, 95% CI 0.06 - 3.35; p= .44). There was no effect of shunt use on the cumulative incidence of restenosis. Post-procedural ipsilateral stroke was not more common in either of the surgical techniques or shunt use. Restenosis was more common after primary closure than conventionally with a patch closure. Shunt use had no effect on restenosis. Patch closure is the treatment of choice to avoid restenosis.

Case of a 69-Year-old Woman With Worsening Renal Insufficiency

We report the case of a 69-year-old woman with worsening renal insufficiency after a recent hospitalization for acute renal failure. Computed tomography angiography revealed a severe calcified coral reef plaque within the paravisceral aorta with severe stenosis of the left renal artery. The patient underwent paravisceral aortic endarterectomy with extended left renal artery eversion endarterectomy and aorto-to-bilateral external iliac artery bypass.

Determination of barometric criteria for rupture of atherosclerotic plaques in the brachiocephalic arteries

The sequence of determining determination of the critical value of blood pressure for the occurrence of dissection of atherosclerotic intima of the internal carotid artery according to the experimental study. Atherosclerotic lesion of the brachiocephalic arteries was modeled on a vascular silicone phantom of the carotid arteries, in which the surgical material (intact annular area of atherosclerotic intima with plaque), obtained after eversion endarterectomy in a patient with atherosclerotic lesions, was placed and fixed in the region of the mouth of the internal carotid artery. A total of 30 models were created. To determine the critical values of the pressure on the intima with the plaque, at which it ruptures, balloon catheters were used, controlling the pressure with a manometer. The results were compared with the preoperative data of ultrasound and computed tomography examinations of patients. Dissection of the intima in the area of the plaque occurred in 6 cases at a pressure of 150180 mm Hg; in 9 cases at 180200 mm Hg, in 3 cases at a pressure of more than 200 mmHg, in 12 when exposed to more than 300 mm Hg. All patients, whose intima ruptured at a pressure of less than 200 mm Hg, had a fluid component of the plaque on preoperative examination, and in 6 patients, the critical pressure on the plaque was 150 mm Hg., there was also a thinned "cover" of the plaque. In the rest of the cases, the plaques were stable without a liquid component. Dissection of the intima in these cases did not occur when the exposure value was more than 300 mm Hg. The presence of a fluid component in an atherosclerotic plaque of the carotid artery in combination with a thinned cover of the plaque indicates the extreme danger of its destruction and embolism during a hypertensive crisis. The degree of stenosis of the carotid artery was found to be a less significant risk factor for unstable plaque rupture than the presence of a fluid component.

Eversion Endarterectomy of the External Iliac Artery in Treating Chronic Limb-Threatening Ischemia in TASC II C and D Iliofemoral Occlusive Disease

Endovascular treatment of iliofemoral occlusive disease is a challenging approach, especially for TransAtlantic Inter-Society C and D lesions. Therefore, the revascularization procedure in such situations is preferably performed by bypass graft surgery with synthetic materials. The purpose of this study is to report the feasibility and mid-term results of eversion endarterectomy of the external iliac artery (EEEIA), as an alternative autologous option. Retrospective study with 18 EEEIA performed between September 2015 and February 2020, exclusively for chronic limb-threatening ischemia treatment in patients with increased risk of postoperative surgical infection and inadvisable for endovascular treatment. Demographic, clinical variables and outcomes were collected from a prospective database. The main end points are: amputation-free survival (AFS) and 30-day mortality. Secondary end points include: primary patency (PP), cumulative patency (CP), overall survival (OS), and postoperative surgical complication. Kaplan-Meier analysis was used to estimate cumulative time of outcomes. The mean age was 64.8 ± 8.3 years, with predominance of men. The median follow-up period was 1012 days, 95% confidence interval [119, 1365] days. Most had Rutherford 5 (n = 13, 72.2%) and mean ankle brachial index was 0.38 ± 0.22. The PP, CP, AFS, and OS in 730 days were 81%, 92%, 80%, and 88%, respectively. There was no 30-day mortality or postoperative surgical infection. Iliofemoral reconstruction through EEEIA is an effective surgical procedure with good patency rates, AFS and OS. In addition, it can be considered an useful and safe option, especially in cases in which a prosthesis should be avoided.

Closure Techniques in Carotid Endarterectomy: Tracing the “Invisible” - Indirect Evidence from Randomised Controlled Trials with a Network Meta-analysis

According to the 2017 clinical practice guidelines of the European Society for Vascular Surgery on the management of atherosclerotic carotid and vertebral artery disease, “Eversion endarterectomy is recommended over routine primary arteriotomy closure”, whereas “The choice between eversion or patched endarterectomy should be left to the discretion of the operating surgeon”.1Naylor A.R. Ricco J.B. de Borst G.J. Debus S. de Haro J. Halliday A. et al.Editor's Choice – management of atherosclerotic carotid and vertebral artery disease: 2017 clinical practice guidelines of the European Society for Vascular Surgery (ESVS).Eur J Vasc Endovasc Surg. 2018; 55: 3-81Abstract Full Text Full Text PDF PubMed Scopus (491) Google Scholar The guidelines also conclude that “There is no evidence that patch type influences outcome”.1Naylor A.R. Ricco J.B. de Borst G.J. Debus S. de Haro J. Halliday A. et al.Editor's Choice – management of atherosclerotic carotid and vertebral artery disease: 2017 clinical practice guidelines of the European Society for Vascular Surgery (ESVS).Eur J Vasc Endovasc Surg. 2018; 55: 3-81Abstract Full Text Full Text PDF PubMed Scopus (491) Google Scholar The study by Lazarides et al. represents a step forward, discriminating between the various patch types and concluding that eversion endarterectomy and patching with bovine pericardium or polytetrafluoroethylene (PTFE) are associated with a similarly low 30 day stroke and death rate, while primary closure and Dacron, vein, or polyurethane patches perform statistically significantly worse.2Lazarides M.K. Christaina E. Argyriou C. Georgakarakos E. Tripsianis G. Georgiadis G. Network meta-analysis of carotid endarterectomy closure techniques.Eur J Vasc Endovasc Surg. 2021; 61: 181-190Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Eversion endarterectomy was also found to be associated with the lowest rate of restenosis compared with all other methods of arterial closure after carotid endarterectomy (CEA). Lazarides et al. have reached these conclusions using a novel and sophisticated methodological approach, called network meta-analysis, and should be commended for this high quality and resource demanding work. This method allows the combination of direct evidence from head to head studies, but additionally extends the analysis to incorporate indirect comparisons across trials based on a common comparator, using the effect estimates of the direct comparisons.3Salanti G. Indirect and mixed-treatment comparison, network, or multiple-treatments meta-analysis: many names, many benefits, many concerns for the next generation evidence synthesis tool.Res Synth Methods. 2012; 3: 80-97Crossref PubMed Google Scholar In this way not only does it give the full picture instead of making pairwise comparisons, but it also ranks the various treatment modalities using summary outputs. In the study by Lazarides et al., eversion endarterectomy ranked first with respect to both 30 day stroke/death and late restenosis rates, followed by PTFE and bovine pericardium patch, although readers should be aware that a high probability of being the best does not necessarily mean a large difference in clinical outcomes.2Lazarides M.K. Christaina E. Argyriou C. Georgakarakos E. Tripsianis G. Georgiadis G. Network meta-analysis of carotid endarterectomy closure techniques.Eur J Vasc Endovasc Surg. 2021; 61: 181-190Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar The evidence provided by Lazarides et al. looks robust enough, as the authors have reported evaluation of the transitivity assumption, implying that it was equally likely that any patient could have been given any of the treatments in the randomised controlled trials network. Moreover, the comparison adjusted funnel plots did not reveal any evidence of asymmetry, with no significant publication bias, thus increasing the validity of the results. However, heterogeneity in definitions among the included studies did not allow the authors to evaluate other than 30 day stroke/death and late restenosis outcomes, while the effect of other covariates could not be assessed in a meta-regression analysis. By updating and promoting the use of universal reporting standards in future studies, we might be able to further focus on modelling multiple outcomes, account for the effect of confounding factors, and draw more conclusions about the optimal closure technique during carotid endarterectomy. Editor's Choice – Network Meta-Analysis of Carotid Endarterectomy Closure TechniquesEuropean Journal of Vascular and Endovascular SurgeryVol. 61Issue 2PreviewThere is discordance between reviews comparing eversion endarterectomy (EvE) with conventional carotid endarterectomy (CEA) mostly because under this term various “closure” techniques are included, from direct closure to a wide spectrum of patches with different materials. Full-Text PDF

A comparison of modified eversion endarterectomy versus classical endarterectomy in the surgical treatment of carotid artery stenosis

A comparison of modified eversion endarterectomy versus classical endarterectomy in the surgical treatment of carotid artery stenosis

The Technique of Eversion Endarterectomy of the Common Femoral Artery

We provide a video depiction of the eversion technique when applied to the femoral endarterectomy. The eversion technique has comparable outcomes to the standard patch angioplasty femoral endarterectomy, and has several advantages, including eliminating the use of patch material.

Disobliteration of an Occluded Common Carotid Artery with Patent Bifurcation via Antegrade Ring Stripping.

There is a lack of guidelines concerning common carotid artery (CCA) occlusive disease in the presence of a patent internal carotid artery (ICA). A novel surgical technique that disobliterates an occluded CCA was successfully performed in three cases. The detailed surgical steps are presented herein. After proximal division of the CCA behind the sternoclavicular junction, the occluded CCA was endarterectomized via antegrade ring stripping. After removal of the atheromatous core, the CCA was everted, and the wall remnants were cleaned under direct vision. Simultaneous eversion endarterectomy of the ICA was performed when necessary. After reversion of the CCA, it was transposed and anastomosed to the ipsilateral subclavian artery distal to the orifice of the vertebral artery. This novel technique can be used in selected cases by experienced surgeons.

Surgical Treatment of Carotid Artery Disease

The rationale for operating on patients with carotid artery disease is to prevent stroke. It has been estimated that in 50 to 80% of patients who experience an ischemic stroke, the underlying cause is a lesion in the distribution of the carotid artery, usually in the vicinity of the carotid bifurcation. Appropriate identification and intervention could significantly reduce the incidence of ischemic stroke. Carotid endarterectomy for both symptomatic and asymptomatic carotid artery stenosis has been extensively evaluated in prospective, randomized trials. Surgical reconstruction of the carotid artery yields the greatest benefits when done by surgeons who can keep complication rates to an absolute minimum. The majority of complications associated with carotid arterial procedures are either technical or judgmental; accordingly, this review emphasizes the procedural aspects of planning and operation considered to be particularly important for deriving the best short- and long-term results from surgical intervention. Specifically, this review covers preoperative evaluation, operative planning, operative technique, postoperative care, follow-up, and alternatives to direct carotid reconstruction. Figures show carotid arterial procedures including recommended patient positioning, the commonly used vertical incision, the alternative transverse incision, mobilization of the sternocleidomastoid muscle to identify the jugular vein, palpation of the internal carotid artery, division of the structures between the internal and external carotid arteries to allow the carotid bifurcation to drop down, division of the posterior belly of the digastric muscle to yield additional exposure of the internal carotid artery, a graphic representation of the measurement of internal carotid artery back-pressure, a central infarct zone surrounded by an ischemic zone, shunt placement, open endarterectomy, eversion endarterectomy, repair of fibromuscular dysplasia, and repair of coiling or kinking of the internal carotid artery. This review contains 17 figures, and 25 references Key words: Carotid artery disease; Carotid endarterectomy; Carotid angioplasty with stenting; Eversion endarterectomy; Open endarterectomy; Carotid plaque; TCAR