Carotid Endarterectomy Patch Research Articles

Patch angioplasty carotid endarterectomy versus eversion carotid endarterectomy.

To compare carotid endarterectomy patch angioplasty (p-CEA) with eversion carotid endarterectomy (e-CEA) and associated risks of early cardio-cerebrovascular complications. The study was a prospective randomized single-blind trial, monocentric, clinically applicable, descriptive analytical and comparative. From June 2021 to June 2023, 62 consecutive patients with symptomatic and asymptomatic stenosis of the internal carotid artery, admitted to our department and randomized into two groups: carotid endarterectomy with patch angioplasty and eversion carotid endarterectomy. Follow-up for 30 days after surgery. During surgery e-CEA, 70% patients had an arrhythmia, and 24 hours after 66.7%, seven days after 46.7% and month after 13.3%. During surgery p-CEA, 33.3% patients had an arrhythmia, 24 hours later 33.3%, 7 days after 13.3% and 30 days after 13.3% patients. Statistically significant difference observed during surgery (Fishers p=0.004). One day after the surgery rate of patients with arrhythmia that were treated e-CEA has decreased, but it was still higher than after p-CEA (Fishers p=0.010). The frequency and categorization of postoperative cardiac arrhythmias after eversion carotid endarterectomy, the clinical implications of various postoperative heart rhythm disturbances and their long-term effects on patients need to be further investigate through sufficiently powered randomized controlled studies.

Outcomes of Carotid Endarterectomy Patch Angioplasty with Polyester and Bovine Pericardium are Similar in a Veteran Population

Outcomes of Carotid Endarterectomy Patch Angioplasty with Polyester and Bovine Pericardium are Similar in a Veteran Population

Comparison Between Conventional and Patch Carotid Endarterectomy: A Single-Center Retrospective Study

BackgroundCarotid endarterectomy (CEA) is most commonly performed via conventional (cCEA)or patch (pCEA) surgical approaches. Current guidelines recommend prioritizing pCEA, however, these recommendations are based on clinical practice of over a decade ago. Under current medical conditions, controversy remains on optimal choice for surgical techniques. ObjectiveTo compare perioperative and long-term safety and effectiveness between cCEA and pCEA. MethodsData on baseline characteristics as well as perioperative and long-term postoperative complications from patients who underwent cCEA or pCEA at the Department of Vascular Surgery, Xuanwu Hospital of Capital Medical University, from 2013 to 2022, were retrospectively collected and analyzed. ResultsA total of 248 CEA patients included in our study. The majority of patients (87.3%) were male, and mean age was 63.6±7.6 (range, 40-81) years; 104 patients (41.9%) underwent cCEA, while 144 (58.1%) underwent pCEA. Between the cCEA and pCEA groups, there were no significant differences in clinical baseline characteristics, occurrence of perioperative or long-term (median, 42.5 [range, 7 to 120] months) complications, and survival whether restenosis-free, asymptomatic or overall. ConclusionIn a single-center experience, conventional and patch CEA approaches appear similarly safe and effective.

Segmented carotid endarterectomy for treatment of Riles type 1A common carotid artery occlusion.

Common carotid artery occlusion (CCAO) is a rare cause of cerebrovascular events. Symptomatic lesions are resistant to medical treatment and revascularization is often required, but there is no consensus on the treatment of CCAO at present. Riles type 1A CCAO is most likely to benefit from revascularization because it has patent outflow tract (internal carotid artery) which was supplied by patent external carotid artery (ECA) from collateral circulation. We described a novel surgical technique improved on the basis of the carotid endarterectomy (CEA) for treatment of Riles type 1A CCAO. We rigorously screened ten patients with symptomatic Riles type1A CCAO for surgery from January 2017 to May 2019 and performed a full preoperative assessment of the inadequate collateral circulation compensation. Moreover, we retrospectively reviewed our experience of the segmented CEA in the treatment of them in our single center. Segmented CEA was performed on the left side in four cases and on the right side in six cases. The technical success rate of the procedure was 100%. Primary suture was used in nine cases. Only one patient (right CCAO) who had a history of neck radiotherapy was treated by the patch CEA. The mean temporary blocking time during surgery was 52.8 ± 9.15min. The mean temporary blocking time for treating the upper segment of the common carotid artery (CCA) was 11.1 ± 2.64min. In the postoperative period, cerebral perfusion on the ipsilateral site improved in all patients, myocardial infarction occurred in one patient, and recurrent laryngeal nerve damage occurred in another. No ischemic events or re-occlusion or restenosis (> 50%) of the treated CCA occurred during the mean follow-up of 32.6 ± 9.3months. The preoperative mean modified Rankin Scale (mRS) score was 1.9 (range, 1-3; median, 2). At last follow-up for all patients, the mRS score was 1 (range, 0-3; median, 1). Segmented CEA, which utilizes the compensatory effect of collateral circulation, is an effective and safe technique to treat patients suffering from Riles type 1A CCAO with hemodynamic cerebrovascular compromise.

Extracellular Matrix Patches for Endarterectomy Repair.

Patch repair is the preferred method for arteriotomy closure following femoral or carotid endarterectomy. Choosing among available patch options remains a clinical challenge, as current evidence suggests roughly comparable outcomes between autologous grafts and synthetic and biologic materials. Biologic patches have potential advantages over other materials, including reduced risk for infection, mitigation of an excessive foreign body response, and the potential to remodel into healthy, vascularized tissue. Here we review the use of decellularized extracellular matrix (ECM) for cardiovascular applications, particularly endarterectomy repair, and the capacity of these materials to remodel into native, site-appropriate tissues. Also presented are data from two post-market observational studies of patients undergoing iliofemoral and carotid endarterectomy patch repair as well as one histologic case report in a challenging iliofemoral endarterectomy repair, all with the use of small intestine submucosa (SIS)-ECM. In alignment with previously reported studies, high patency was maintained, and adverse event rates were comparable to previously reported rates of patch angioplasty. Histologic analysis from one case identified constructive remodeling of the SIS-ECM, consistent with the histologic characteristics of the endarterectomized vessel. These clinical and histologic results align with the biologic potential described in the academic ECM literature. To our knowledge, this is the first histologic demonstration of SIS-ECM remodeling into site-appropriate vascular tissues following endarterectomy. Together, these findings support the safety and efficacy of SIS-ECM for patch repair of femoral and carotid arteriotomy.

Long-term impact of the Vascular Study Group of New England carotid patch quality initiative

ObjectivePatch angioplasty has been shown to decrease rates of restenosis after carotid endarterectomy (CEA). In 2003, the Vascular Study Group of New England (VSGNE) implemented its first quality initiative aimed at increasing the rates of patch closure after CEA. This study reports the effects of that initiative on the rate of patch closure in the VSGNE and also postoperative and 1-year CEA outcomes. MethodsPatients undergoing CEA (N = 14,636) within the VSGNE between 2003 and 2014 were studied. Rates of in-hospital postoperative events (death, ipsilateral stroke or transient ischemic attack [TIA], and return to the operating room for bleeding) and events during 1 year of follow-up (stroke or TIA and restenosis >70% or occlusion) were compared by repair type—patch closure, primary closure, or eversion. One-year follow-up events were also compared over time and by annualized surgeon volume. ResultsDuring the 12 years studied, patch use increased from 71% to 91% (P < .001). There was no difference in postoperative death or ipsilateral stroke or TIA between the repair types. However, there was a statistically lower rate of return to the operating room for bleeding (P < .001), 1-year stroke or TIA (P < .003), and 1-year restenosis or occlusion (P < .001) with patch closure. Overall, the rates of 1-year stroke or TIA and restenosis decreased over time in the VSGNE. The initiative affected patch closure rates and outcomes of high-volume surgeons (>47 CEAs/y) the most. High-volume surgeons increased patch use from 50% to 90% and decreased their restenosis rates from 9.0% to 1.2% and 1-year stroke or TIA from 4.9% to 1.9% (P < .001). ConclusionsThe VSGNE carotid patch quality initiative successfully increased the rates of CEA patch closure. During the same time, there has been a decrease in postoperative bleeding requiring reoperation and 1-year ipsilateral neurologic events and restenosis or occlusion.

Early hemodynamic characteristics of eversion and patch carotid endarterectomies.

Carotid endarterectomy (CEA) is currently the gold standard in the operative management of carotid artery stenosis. While eversion and patch CEAs vary greatly in technique, various studies have determined equivalence with regard to clinical outcomes. However, the hemodynamic differences following each procedure are not known. This study aimed to investigate any early hemodynamic differences between eversion and patch CEAs. All CEAs performed at our institution from March 2012 to June 2018 were aggregated in a retrospective database by querying the 35301 CPT code from the electronic medical record system. Variables collected included gender, age, laterality of CEA, type of procedure, and pre- and post-operative duplex ultrasound (DUS) date and quantitative findings. Exclusion criteria included any procedure with incomplete data, a post-operative DUS > 90days following the procedure, CEAs with concomitant bypass(es), isolated external carotid artery (ECA) endarterectomies, and re-do CEAs. One hundred and seventy-one CEAs were performed in 161 unique patients. There were 101 males and 60 females, with an average age of 69.7 (38-96; ± 9.36). 63 CEAs were excluded from analysis: 51 due to incomplete data, eight with a > 90 day post-operative DUS, 2 isolated ECA endarterectomies, 1 CEA with a carotid-subclavian bypass, and 1 re-do CEA secondary to an infected patch. Twenty-seven eversion and 81 patch CEAs were included in analysis. There was no difference in procedure laterality or gender between the two cohorts (p > 0.05); however, patients who received an eversion CEA were older on average (73.3 vs 67.5; p = 0.002). Pre-operative peak systolic velocities (PSV) of the proximal internal carotid artery (ICA), distal ICA, and distal common artery (CCA) were all similar (p > 0.05). Post-operative DUS was performed at 17.0 and 12.9days in the eversion and patch CEA cohorts, respectively (p = 0.12). Post-operative PSV and change in PSV were similar for all three aforementioned segments (p > 0.05). Although eversion and patch CEAs vary greatly in technique and post-procedure anatomy, there was no significant difference in post-operative PSV or change in PSV at or around the carotid bifurcation.

Management of patch infections after carotid endarterectomy and utility of femoral vein interposition bypass graft

ObjectivePatch infection after carotid endarterectomy (CEA) is a rare but devastating complication. A variety of different treatment options are reported; however, there is currently no consensus on how to manage this highly morbid problem. The purpose of this study was to review our experience with management of infectious patch complications after CEA and to highlight utility of femoral vein interposition bypass grafting. MethodsAll CEA patch infection operations at the University of Florida from 2002 to 2017 were reviewed retrospectively. Preoperative history, intraoperative details, and postoperative complications were recorded. Bypass patency was verified with duplex ultrasound imaging (1 month, 6 months, annually). The primary end point was 30-day stroke or death; secondary end points included cranial nerve injury, reintervention, reinfection, and survival. Life tables were used to estimate end points. ResultsTwenty-nine patients (mean age, 70 ± 9 years; male, 76%) were identified. The index CEA occurred at a median of 15 months (interquartile range, 1-55 months) preoperatively (39% <2 months after the index procedure). A variety of patch materials were implicated (Dacron, n = 9; unknown/undocumented, n = 8; bovine pericardium, n = 5; expanded polytetrafluoroethylene, n = 3; unidentified nonbiologic prosthetic, n = 3; saphenous vein, n = 1). Carotid reintervention antecedent to the infected patch presentation occurred in 41% (incision and drainage, n = 10; carotid stent, n = 2; vein patch, n = 1). The most common infecting organisms were Staphylococcus and Streptococcus species (52%; n = 15). The most frequent presentation (46%; n = 13) was pericarotid abscess or phlegmon (pulsatile neck mass or pseudoaneurysm, 28% [n = 8]; carotid-cutaneous fistula, 28% [n = 8]). Reconstruction strategy included femoral vein interposition bypass in 24 patients (83%; nonreversed configuration, 16/24 [67%]), saphenous vein patch in 4 patients (14%), and femoral vein patch in 1 patient (3%). Median postoperative length of stay was 5 days (interquartile range, 4-8 days). Twelve patients (41%) experienced a complication, and the 30-day stroke/death rate was 7% (death, n = 1; stroke, n = 1). The single postoperative death occurred in a patient with history of congestive heart failure who developed a pulseless electrical activity arrest on postoperative day 11 that resulted in multiorgan system failure. Cranial nerve injury occurred in 28% (n = 8; cranial nerves X [3], VII [2], XII [2], and IX [1]), all of which resolved by last follow-up. In follow-up (mean clinical follow-up, 17 ± 14 months; mean survival time, 108 months [95% confidence interval, 81-135 months]), two (7%) complained of limb edema with femoral cutaneous nerve palsy that resolved by 3 months. One interposition bypass occluded at 3 months (asymptomatic); the remaining grafts remained patent with no restenosis, reinfection, or reintervention events. The 1- and 5-year survival was 87% ± 6% and 82% ± 8%, respectively. ConclusionsCEA patch infection can be successfully managed with femoral vein interposition bypass with acceptable postoperative outcomes. Excellent patency can be anticipated with good long-term survival. This strategy can be considered especially in cases with carotid size mismatch or if there is limited availability of alternative biologic conduits.

Carotid endarterectomy for severe symptomatic carotid artery stenosis

Objective To investigate the clinical efficacy of carotid endarterectomy (CEA) in the treatment of extremely severe symptomatic carotid artery stenosis (stenosis rate 95%-99%). Methods The clinical data of 30 patients with extremely severe symptomatic carotid artery stenosis were analyzed retrospectively. Those patients were admitted to Department of Neurosurgery, the First Affiliated Hospital of Soochow University between January 2013 and December 2016. Among them, 14 cases underwent conventional CEA, 11 cases received patch CEA and 5 cases underwent eversion CEA. Cerebral hemisphere perfusion was evaluated with CT Perfusion (CTP) and cerebrovascular collateral circulation was evaluated with DSA or CTA. Results All 30 cases of CEA were performed successfully. CTP was reviewed at 1 week post surgery and all patients had a higher CBF (cerebral blood flow) compared with presurgical states (65.1±8.9 ml·100 g-1·min-1vs. 48.5±5.1 ml·100 g-1·min-1,P<0.05), and the TTP (time-to-peak) was significantly shorter than that prior to surgery (9.8±2.8 s vs. 13.4±1.6 s, P<0.05). After operation, 3 cases suffered from hyperperfusion syndrome. There was no perioperative stroke or death. The duration of follow-up was 3-48 months (mean: 20±12 months). No patient developed a new stroke.No reocclusion was detected. Conclusion CEA seems to be a safe and effective treatment for extremely severe symptomatic carotid artery stenosis. Key words: Carotid stenosis; Atherosclerosis; Endarterectomy, carotid; Treatment outcome

Long-Term Effect of the Type of Carotid Endarterectomy on Blood Pressure

The dissection of the carotid sinus nerve in eversion carotid endarterectomy (eCEA) has been hypothesized to cause an increase in postoperative blood pressure (BP). The objective of this study is to evaluate the effect of eCEA on BP and changes in BP medications over the course of year-long follow-up after eCEA compared with longitudinal incision carotid endarterectomy patch angioplasty (pCEA). A retrospective review of patients who underwent CEA between July 1, 2009 and June 30, 2014 in the Vascular Surgery Department at The University of Iowa Hospital and Clinics was conducted. Demographics, comorbidities, BP, and number, dosage, and type of antihypertensive medications were collected preoperatively, at 30 days, and at 12 months. The differences in BP and medications between pCEA and eCEA patients were compared. Demographic data and comorbidities were compared using t-tests and chi-squared analysis. Differences in BP and medication dosages were analyzed using multivariate analysis of variance. In total, 363 CEA procedures were performed during the study period, of which 275 procedures were included in the final analysis. Thirty percent of the patients underwent eCEA. Fifty-four percent of the patients who underwent eCEA and 60% of the patients who underwent pCEA were symptomatic. Thirty-day mortality was 1.4% and 12-month mortality was 6.4% for the entire population. No postoperative neurologic deficits, including stroke, were observed. Analysis of BP did not yield a significant difference among preoperative, 30-day, and 12-month follow-up measurements (P=0.893). There was no significant change to the number and total daily dose of BP medications preoperatively, at 30days, or at 12months. There is no statistical difference in mortality, morbidity, and patency rates at 30days and 12months between pCEA and eCEA. eCEA is also not associated with long-term BP changes compared with pCEA.

Surgical management of post carotid artery stenting restenosis

To discuss the feasibility, safety and effectiveness of surgical management of post carotid artery stenting (CAS) restenosis, mainly focusing on the surgical options and indications. This study represented retrospective analysis of 3 kinds of surgical managements of 21 patients with symptomatic post CAS restenosis from April 2012 to April 2014. Patch carotid endarterectomy (pCEA), Eversion carotid endarterectomy (eCEA) or carotid excision and graft interposition (CEGI) was selected to remove the stent and reconstruct the blood flow, based on the preoperative imaging results and intraoperative adhesion degree. Use of carotid shunt, blood loss, operative time, carotid artery cross-clamp time and other data were recorded. Patients were followed for improvement of symptoms, complications and restenosis. Eleven, 4 and 6 patients received pCEA, eCEA or CEGI respectively. All the stents were successfully removed. Shunts were deployed in 14 cases. The mean bleeding was (152.6 ± 38.0) ml, the mean operation time was (100.7 ± 34.8) min and the mean carotid artery clamping time was (29.1 ± 4.6) min. In the early postoperative period, there were no infection, strokes, cranial nerve injury, myocardial infarction or mortalities. One patient developed neck hematoma, while 2 patients had the symptoms of hyperperfusion such as headache, irritability and multi-lingual but no intracranial hemorrhage happened according to the brain CT scan, who all fully recovered within 3 days. Within a median follow-up of (13.2 ± 4.3) months, no strokes, myocardial infarctions or recurrent restenosis (> 50%) on duplex ultrasound imaging or CTA was discovered except for 1 patient who died of lung cancer. Surgical management to remove the stent and reconstruct the blood flow, which offered new options in the treatment of post CAS restenosis, with its initially confirmed simplicity, feasibility, safety and validity.

Patient controlled epidural therapy in labouring women

The dissection of the carotid sinus nerve in eversion carotid endarterectomy (eCEA) has been hypothesized to cause an increase in postoperative blood pressure (BP). The objective of this study is to evaluate the effect of eCEA on BP and changes in BP medications over the course of year-long follow-up after eCEA compared with longitudinal incision carotid endarterectomy patch angioplasty (pCEA).A retrospective review of patients who underwent CEA between July 1, 2009 and June 30, 2014 in the Vascular Surgery Department at The University of Iowa Hospital and Clinics was conducted. Demographics, comorbidities, BP, and number, dosage, and type of antihypertensive medications were collected preoperatively, at 30 days, and at 12 months. The differences in BP and medications between pCEA and eCEA patients were compared. Demographic data and comorbidities were compared using t-tests and chi-squared analysis. Differences in BP and medication dosages were analyzed using multivariate analysis of variance.In total, 363 CEA procedures were performed during the study period, of which 275 procedures were included in the final analysis. Thirty percent of the patients underwent eCEA. Fifty-four percent of the patients who underwent eCEA and 60% of the patients who underwent pCEA were symptomatic. Thirty-day mortality was 1.4% and 12-month mortality was 6.4% for the entire population. No postoperative neurologic deficits, including stroke, were observed. Analysis of BP did not yield a significant difference among preoperative, 30-day, and 12-month follow-up measurements (P = 0.893). There was no significant change to the number and total daily dose of BP medications preoperatively, at 30 days, or at 12 months.There is no statistical difference in mortality, morbidity, and patency rates at 30 days and 12 months between pCEA and eCEA. eCEA is also not associated with long-term BP changes compared with pCEA.

Carotid Endarterectomies in Latvia

Carotid Endarterectomies in Latvia Introduction. Carotid endarterectomy (CEA) is a treatment of choice for significant carotid stenosis, and it has an important role in stroke prophylaxis, that is proved in many trials all over the world. Aim of the study. To evaluate preoperative diagnostic methods, risk factors and co-morbidities, operation results for patients undergoing CEA in Latvia. To analyze used anaesthasia and operation technique in CEA in Latvia. To reflect carotid endarterecomy results that depends from chosen operation technique. Materials and methods. 317 patients were included in the retrospective study from January 1st till December 31st, 2008. Patient charts were evaluated for information about history of disease and other comorbidities, preoperative investigation, operation and early postoperative period followed by protocol. All patients were divided into three groups depending on type of endarterectomy (CEA with primary suture, with patch or eversion CEA). Results. In 59% cases carotid disease were asymptomatic. Computer tomography angiography (CTA) and duplex ultrasound were the most common diagnostic methods to evaluate carotid stenosis. 339 carotid endarterectomies were performed, where CEA with primary suture was used in 56.2% of cases (group 1). There were no significant diferences in patient atherosclerotic risks factors, comorbidities, preoperative investigation methods, time of surgery and complications rate between the groups. Conclusions. In Latvia carotid endarterectomy is carried out mostly in classical conventional tecniques and arteriotomy is being closed with a primary suture.

Primary Closure, Routine Patching, and Eversion Endarterectomy: What is the Current State of the Literature Supporting Use of These Techniques?

Our objective in this article was to review the most recent literature on the status of carotid patching or primary carotid closure following carotid endarterectomy; to determine the best patch material if needed; and to clarify the place of eversion carotid endarterectomy in management of carotid artery atherosclerosis. In order to accomplish this, a literature review was performed of the Ovid, PubMed and MedLine databases using appropriate search terms. An evidence-based approach was taken; with all articles graded using the Scottish Intercollegiate Guidelines Network system (levels of evidence 1 to 5) and recommendations were made using an A to D system. Most weight was given to well-conducted, adequately powered, randomized control trials. After review of the literature, we were able to make the following Grade A recommendation: carotid patching is superior to primary closure, resulting in fewer postoperative strokes and a lower incidence of restenosis in most surgeons' hands. However, it was also concluded that, based on review of the literature, that the choice of patch material in 2007 has little impact; eversion carotid endarterectomy (CEA) and conventional patch CEA have equivalent postoperative morbidity and similar incidences of long-term restenosis. In conclusion, the technique of CEA continues to evolve, but in most reported series, immediate and long-term outcomes are excellent. A variety of technical approaches are acceptable, but it appears that carotid patching remains superior to primary closure.

Restenosis after eversion vs patch closure carotid endarterectomy

Recurrent stenosis after carotid endarterectomy (CEA), previously reported to occur in 1%/year after operation, is the finite limitation of CEA. Eversion endarterectomy has a perceived lower incidence of recurrent stenosis, although data to support this contention are conflicting. The goal of the present study was to compare the late anatomic results of patch closure (PC) vs eversion CEA. Between January 1, 1995 and June 30, 2005, 950 CEA were performed by the senior author with adoption of eversion (EV) as the primary technique as of January 1, 2001. With minimum of 1-year follow-up by study inclusion criteria, complete follow-up data (including a duplex scan) was available for 155 PC and 135 EV patients. Incidence of moderate (50% to 70%) and severe (>70%) restenosis was examined at < or =2 months and >1 year after operation. Study end-points included late stroke, survival, and freedom from restenosis (moderate and severe) and were assessed by actuarial methods. There were no differences in relevant demographic/clinical parameters, indication for surgery (69% overall asymptomatic) or early perioperative stroke/death (1.1% overall; P = .25) between PC and EV. After correction for different mean follow-up intervals (PC = 5.5 years vs EV = 3.5 years) by actuarial methods, there was no significant difference in late moderate (P = .91) or severe (P = .54) recurrent stenosis between PC and EV. In the group of patients with at least 1-year follow-up, 11/290 (3.8%) patients (4/135 EV, 7/155 PC; P = .39) required reintervention on their operated carotid artery at a cumulative follow-up interval of 4.5 years. Three strokes (3/290; 1.1%) occurred during late follow-up, all in the PC group, with only one related to the operated carotid artery. Late survival was similar between EV and PC, (P = .86). Female gender (odds ratio [OR] 3.72[1.02-13.5], P = .046) was associated with severe restenosis irrespective of surgical technique. Univariate analysis also showed that female gender (OR 7.6[CI: 0.88-66.7], P = .042) was associated with late stroke. These findings indicate that restenosis rates are similar between eversion and patch CEA and likely represent biological remodeling phenomenon rather than technical variations of operations. While EV offers distinct advantages in certain anatomic circumstances, adoption of EV with the hope of decreasing restenosis is not warranted.

Late Infection of a Dacron Carotid Endarterectomy Patch

This unique case reports the nonsurgical management of a late (2 years) methicillin-resistant Staphylococcus aureus neck infection around a Dacron-patched carotid endarterectomy. Because the patient was elderly with multiple serious risk factors and no drainable material, IV and oral antibiotics were selected as initial management. Follow-up computed tomography of the neck, however, documented complete resolution of the phlegmon. While the authors remain uncertain of the long-term outcome the patient is free of local infection 2 years after diagnosis and nonoperative treatment.

Eversion versus conventional carotid endarterectomy: Late results of a prospective multicenter randomized trial

Objective: The durability of carotid endarterectomy (CEA) may be affected by carotid restenosis. The data from randomized trials show that the highest incidence of restenosis after CEA occurs from 12 to 18 months after surgery. The optimal CEA technique to reduce perioperative complications and restenosis rates is still undefined. This study examines the long-term clinical outcome and incidence of recurrent stenosis in patients who undergo eversion CEA. Previously published perioperative results of this study did not show statistically significant differences in study endpoints between the eversion and standard techniques. Methods: From October 1994 to March 1997, 1353 patients with surgical indications for carotid stenosis were randomly assigned to undergo eversion (n = 678) or standard CEA (n = 675; primary closure, 419; patch, 256). Withdrawal from the assigned treatment occurred in 1.6% of the patients (in 13 assigned to eversion CEA, and in nine assigned to standard CEA). The clinical and duplex scan follow-up examination was 99% complete, and the mean follow-up interval was 33 months (range, 12 to 55 months). The primary outcomes were perioperative and late major stroke and death, carotid restenosis (stenosis ≥ 50% of the lumen diameter detected at duplex scanning), and carotid occlusion. The primary evaluation of study outcomes was conducted on the basis of an intention-to-treat analysis. Results: Restenosis was found at duplex scanning in 56 patients (19 in the eversion group, and 37 in the standard group). Within the standard group, the restenosis rates were 7.9% in the primary closure population and 1.5% in the patched population. Of the patients with restenosis, 36% underwent cerebral angiography that confirmed restenosis in all cases. The cumulative restenosis risk at 4 years was significantly lower in the group that underwent treatment with eversion CEA as compared with the standard group (3.6% vs 9.2%; P = .01), with an absolute risk reduction of 5.6% and a relative risk reduction of 62%. Eighteen patients would have had to undergo treatment with eversion CEA to prevent one restenosis during the 4-year period. The incidence rate of ipsilateral stroke was 3.3% in the eversion population and 2.2% in the standard group. There were no significant differences in the cumulative risks of ipsilateral stroke (3.9% for eversion, and 2.2% for standard; P = .2) and death (13.1% for eversion, and 12.7% for standard; P = .7)) in the two groups. Of the 18 variables that were examined for their influence on restenosis, eversion CEA (hazard ratio, 0.3; 95% confidence interval, 0.2 to 0.6; P = .0004) and patch CEA (hazard ratio, 0.2; 95% confidence interval, 0.07 to 0.6; P = .002) were negative independent predictors of restenosis with multivariate Cox proportional hazards regression analysis. Conclusion: The EVEREST (EVERsion carotid Endarterectomy versus Standard Trial) showed that eversion CEA is safe, effective, and durable. No statistically significant differences were found in late outcome between the eversion and standard techniques at the available follow-up examination. (J Vasc Surg 2000;31:19-30.)

Is There Carotid Artery Aneurysm Formation following Saphenous Vein Patch Endarterectomy?

The use of saphenous vein patching following carotid endarterectomy is reported to produce aneurysmal dilatation with the risk of thrombosis and possible rupture. The authors have studied patients who have had saphenous vein patch angioplasty following carotid endarterectomy to assess whether there is any progressive arterial dilatation. Thirty-five patients who had undergone saphenous vein patch carotid endarterectomy were age- and sex-matched with 31 subjects that had direct closure endarterectomy. All participants underwent carotid duplex scanning. The external diameters of the mid common carotid artery, the bulb and the proximal internal carotid artery were measured bilaterally. The diameters of the endarterectomized carotid were compared with the contralateral side using a paired t-test. Using an unpaired t-test the saphenous vein angioplasty group was compared with the directly closed group A graph was plotted of the ratio of internal carotid artery diameter of the saphenous vein angioplasty group (endarterectomized artery to the contralateral artery) against the length of follow-up, and the Pearson correlation coefficient was calculated. When the saphenous vein angioplasty group was compared with the directly closed group there was a significant difference between the carotid bulb (11.6 versus 9.7 mm. P &lt; 0.001) and internal carotid artery diameters (9.0 versus 7.0 mm. P &lt; 0.001). Longitudinal analysis of the saphenous vein angioplasty group showed that the increased diameter of the endarterectomized internal carotid artery progressed with time after surgery ( r = 0.51. P &lt; 0.005. and r = 0.56 P &lt; 0.001). Vein patching increases the diameter of the internal carotid artery, and this may further increase with time possibly predisposing to aneurysm formation. Further longitudinal studies of paired data are required.

Is there carotid artery aneurysm formation following saphenous vein patch endarterectomy?

The use of saphenous vein patching following carotid endarterectomy is reported to produce aneurysmal dilatation with the risk of thrombosis and possible rupture. The authors have studied patients who have had saphenous vein patch angioplasty following carotid endarterectomy to assess whether there is any progressive arterial dilatation. Thirty-five patients who had undergone saphenous vein patch carotid endarterectomy were age- and sex-matched with 31 subjects that had direct closure endarterectomy. All participants underwent carotid duplex scanning. The external diameters of the mid common carotid artery, the bulb and the proximal internal carotid artery were measured bilaterally. The diameters of the endarterectomized carotid were compared with the contralateral side using a paired t-test. Using an unpaired t-test, the saphenous vein angioplasty group was compared with the directly closed group. A graph was plotted of the ratio of internal carotid artery diameter of the saphenous vein angioplasty group (endarterectomized artery to the contralateral artery) against the length of follow-up, and the Pearson correlation coefficient was calculated. When the saphenous vein angioplasty group was compared with the directly closed group there was a significant difference between the carotid bulb (11.6 versus 9.7 mm, P<0.001) and internal carotid artery diameters (9.0 versus 7.0 mm, P<0.001). Longitudinal analysis of the saphenous vein angioplasty group showed that the increased diameter of the endarterectomized internal carotid artery progressed with time after surgery ( r=0.51, P<0.005, and r=0.56, P<0.001). Vein patching increases the diameter of the internal carotid artery, and this may further increase with time possibly predisposing to aneurysm formation. Further longitudinal studies of paired data are required.

Carotid Patching: What is the Optimum Patch Material?

A growing body of evidence indicates that obligatory or highly frequent carotid endarterectomy (CEA) patch reconstruction gives superior peri operative and late outcomes. With average combined perioperative stroke and mortality rates for CEA in the 5 to 6% range, the 3 to 4% improvement in this outcome offered by patching is clinically highly significant. A major unanswered question is which patch material or materials provide the optimal protection against perioperative stroke and restenosis. Only two prospective randomized studies contain two or more carotid patch materials, and, like nonrandomized reports containing two or more patch materials, the sample sizes are too small to draw accurate statistical conclusions. This problem is circumvented by an infor mal meta analysis of pooled data from published reports containing outcomes for CEA patch reconstruction with two or more of the following materials: autolo gous greater saphenous vein, everted or double-layered cervical vein, Dacron, and polytetrafl...