Vein-patch rupture after carotid endarterectomy: an avoidable catastrophe

Carotid endarterectomy with saphenous vein patch angioplasty: a single-center experience

BACKGROUND

When performing a conventional CEA it is recommended the use of patch angioplasty (PA), since previous meta-analyses have shown PA to be superior to primary closure (PRC) in terms of stroke and restenosis rates. Different materials patches can be employed although none of them has been proved to be superior. Although autologous veins are potentially more resistant to immediate thrombosis as well as infection, cons may be represented by patch rupture and late dilatation. Aim of this study is to evaluate immediate and long-term results of CEA with saphenous vein patch angioplasty (SVPA) in a single-center experience.

METHODS

A retrospective study was performed analyzing all patients undergoing CEA with SVPA at our institution from January 2012 to March 2020. CEA was performed in symptomatic patients with 50-99% carotid stenosis degree or asymptomatic patients with 70-99% stenosis degree. Exclusion criteria were critical limb ischemia, varicose disease, unavailability of saphenous veins, vein diameter <3.5 mm. All CEAs were performed under general anesthesia with routine shunting. Primary endpoints were perioperative stroke, death, carotid thrombosis and hematoma requiring surgery rates. Secondary endpoints included the rate of recurrent stenosis >70%, patch aneurysm/rupture/infection at follow-up.

RESULTS

Overall, 488 interventions were performed on 461 patients. Most patients were male (77.8%) with a mean age of 71.2±8.3 years. Thirty-day mortality and stroke rates were 0.4% and 1.2% respectively. Carotid thrombosis occurred in five patients (1%). Five patients (1%) developed a surgical site hematoma requiring surgical drainage. At a mean follow-up of 34.4±25.8 months 12 restenoses (2.5%) were detected. Five-year freedom from restenosis rate was 96.7%. Restenosis at follow-up was more frequent in patients who had contralateral carotid stenosis (P=0.019). Two patients (0.4%) developed carotid patch aneurysmal degeneration at a mean follow-up of 78.7 months. No infection nor patch disruption were detected.

CONCLUSIONS

CEA with SVPA resulted safe and effective in terms of early and late results. The perioperative complications rates we recorded were quite similar to those reported by other larger reviews and meta-analyses.

Durability of Carotid Endarterectomy with Bovine Pericardial Patch

BACKGROUND

Multiple studies have shown that patch angioplasty after carotid endarterectomy (CEA) reduces the risk of stroke and restenosis when compared with primary closure. Biological, synthetic, or vein patches have been traditionally used in CEA. This article reports the early and long-term outcomes of bovine pericardium (BP) for patch angioplasty in CEA.

METHODS

A retrospective, consecutive analysis of 874 patients who underwent CEA during the past 17 years at Mayo Clinic, Florida, was performed. BP patch (BPP) was used in 680 patients. Other CEA techniques were used in 194 patients (standard without patch, 78; standard with Dacron, 74; standard with vein patch, 16; and other techniques: bypasses, 26). We defined group 1 as those who underwent BPP angioplasty and group 2 as those who underwent all other techniques. Early and late clinical outcomes and patch-related complications (restenosis, infection, and hematoma) were recorded and analyzed.

RESULTS

Median follow-up for the entire series was 39.6 months. There were no statistically significant differences in 30-day mortality and morbidity between the 2 groups, except that BP group has less 30-day stroke (0.1%, 1 of 680) versus other techniques (1.5%, 3 of 194, P = 0.03). Thirty-day postoperative mortality rate was 0.1% (1 of 680) in BPP group and 1.0% (2 of 194) in other technique group (P = 0.13). No statistically significant difference was noted in 30-day postoperative major complications (transient ischemic attack [TIA], wound infection, hematoma requiring surgical evacuation, and nerve injury) between the 2 groups. Ten-year freedom from stroke/TIA were 97.8% in the BP group compared with 98.5% in the other group (P = 0.86). Ten-year freedom from restenosis was also similar between groups (89.0% BP vs. 90.4% others, P = 0.69). Ten-year survival rate was 38.4% in BP group and 45.0% in other technique group, and this was statistically significant on univariate analysis only.

CONCLUSIONS

CEA with BP angioplasty has excellent early and late outcomes with minor morbidity and mortality.

Patches for carotid artery endarterectomy: current materials and prospects

Patch angioplasty is commonly performed after carotid endarterectomy. Randomized prospective trials and meta-analyses have documented improved rates of perioperative and long-term stroke prevention as well as reduced rates of restenosis for patches compared with primary closure of the arteriotomy. Although use of vein patches is considered to be the gold standard for patch closure, newer generations of synthetic and biologic materials rival outcomes associated with vein patches. Future bioengineered patches are likely to optimize patch performance, both by achieving minimal stroke risk and long-term rates of restenosis as well as by minimizing the risk of unusual complications of prosthetic patches such as infection and pseudoaneurysm formation. In addition, lessons from bioengineered patches will likely enable construction of bioengineered and tissue-engineered bypass grafts.

Carotid endarterectomy in the U.K. and Ireland: audit of 30-day outcome. The Audit Committee for the Vascular Surgical Society

OBJECTIVES AND DESIGN

A prospective study of 709 patients undergoing carotid surgery in the U.K. and Ireland was performed to evaluate the performance of vascular surgeons.

MATERIALS AND METHODS

Fifty-nine surgeons (range 2-39 cases each) were sampled and all patients undergoing surgery over a 6-month period (1 March 1994-31 August 1994) were included in the study. Indications for surgery were TIA (35.9%), AF (23.3%), CVA (21.4%) and "others" (19.6%).

RESULTS

Mean ipsilateral stenosis was 82% (30%-99%). Thirty-one percent of patients had preoperative neurological consults. Shunts were used in 67.6%, tacking sutures in 40.1%, drains in 71.9% and patches in 54.4% of cases. At 30 days there were nine (1.3%) deaths (four cardiac, three neurological). There were 15 ipsilateral postoperative CVAs (2.1%); 19% of patients had one or more complication, usually minor. Statistical analysis showed no independent risk factor for CVA other than seniority of the surgeon.

CONCLUSIONS

A combined stroke/death rate of 3% for the series was obtained at 30 days for all cases. This large, validated study suggests that members of the Vascular Society of G.B. and Ireland currently have a very low morbidity/mortality rate for performing carotid surgery. Continued audit is required to ensure that this quality of service does not deteriorate.

The practice of carotid endarterectomy in Australasia

BACKGROUND

Carotid endarterectomy (CEA) is a frequently performed surgical procedure and there are variations in the preoperative, operative and postoperative management related to this operation.

METHODS

Questionnaires were sent to all 191 members of the Division of Vascular Surgery, Royal Australasian College of Surgeons, and the Australasian Chapter of the International Society of Cardiovascular Surgery.

RESULTS

The questionnaire was returned by 179 surgeons (94%). One hundred and fifty-nine were vascular surgeons, of whom 139 perform CEA. Most surgeons reported performing more CEA than 5 years previously. Surgery for asymptomatic carotid stenosis was performed by 78% of surgeons at the time of the survey. Routine carotid angiography is performed pre-operatively for symptomatic patients by 61% of surgeons and for asymptomatic patients by 56%. Intra-operative shunting is used routinely by 37% of surgeons, selectively by 58% and never by 5%. Arteriotomy patch closure is performed routinely by 16%, usually by 30%, rarely by 52% and never by 3%. The favoured patch material is Dacron 39%, PTFE 19%, ankle long saphenous vein (LSV) 22%, thigh LSV 18% or other materials 2%. Compared to their practice 5 years previously, arterial patch closure is used more often by 42% of surgeons, the same by 51% and less by 7%. Postoperatively, patients are nursed mainly in intensive care (34%) or a high-dependency unit (33%).

CONCLUSIONS

The practice of CEA by Australasian vascular surgeons reflects the recent trends reported in the world literature. Most Australasian surgeons perform CEA for asymptomatic disease. Forty per cent are performing CEA on the basis of duplex scanning alone. There is a trend towards increased use of patch closure. Most patients are managed in intensive care or high-dependency units.

Carotid endarterectomy in Great Britain and Ireland: practice between 1984 and 1992

Of 356 questionnaires on carotid endarterectomy sent to all vascular surgeons in Great Britain and Ireland likely to undertake this procedure, 326 (92 per cent) were returned. Of those who replied 131 (40 per cent) performed at least one carotid endarterectomy in 1992; 57 (44 per cent) of these carried out ten or fewer operations and 74 (56 per cent) more than ten. The 131 surgeons were collectively responsible for 2628 operations in 1992, twice as many as were undertaken in either 1984 or 1989, years for which similar survey data are available. This sharp rise in the number of operations was accounted for by increased activity on the part of experienced operators, rather than any rise in the number of 'occasional' carotid surgeons. In 1992, although the neurologist remained a major source of patient referral, general practitioners (and others) were also referring patients in large numbers direct to the vascular surgeon; this represents a change in practice compared with previous years. Many of the technical aspects surrounding carotid endarterectomy remained unchanged over the years surveyed (1984, 1989, 1992) but by 1992 duplex scanning, intra-arterial (but not intravenous) digital subtraction angiography and transcranial Doppler ultrasonography had become established as clinically useful techniques.