Late follow-up of carotid endarterectomy with venous patch angioplasty

Comparative Review of the Treatment Methodologies of Carotid Stenosis

The treatment of carotid stenosis entails three methodologies, namely, medical management, carotid angioplasty and stenting (CAS), as well as carotid endarterectomy (CEA). The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) have shown that symptomatic carotid stenosis greater than 70% is best treated with CEA. In asymptomatic patients with carotid stenosis greater than 60%, CEA was more beneficial than treatment with aspirin alone according to the Asymptomatic Carotid Atherosclerosis (ACAS) and Asymptomatic Carotid Stenosis Trial (ACST) trials. When CAS is compared with CEA, the CREST resulted in similar rates of ipsilateral stroke and death rates regardless of symptoms. However, CAS not only increased adverse effects in women, it also amplified stroke rates and death in elderly patients compared with CEA. CAS can maximize its utility in treating focal restenosis after CEA and patients with overwhelming cardiac risk or prior neck irradiation. When performing CEA, using a patch was equated to a more durable result than primary closure, whereas eversion technique is a new methodology deserving a spotlight. Comparing the three major treatment strategies of carotid stenosis has intrinsic drawbacks, as most trials are outdated and they vary in their premises, definitions, and study designs. With the newly codified best medical management including antiplatelet therapies with aspirin and clopidogrel, statin, antihypertensive agents, strict diabetes control, smoking cessation, and life style change, the current trials may demonstrate that asymptomatic carotid stenosis is best treated with best medical therapy. The ongoing trials will illuminate and reshape the treatment paradigm for symptomatic and asymptomatic carotid stenosis.

Systematic review of randomized controlled trials of different types of patch materials during carotid endarterectomy

Background and Purpose

Carotid 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.

Methods

A 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.

Results

Thirteen 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).

Conclusions

The 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.

Acute platelet deposition after carotid endarterectomy in sheep: vein patch compared with gelatin-sealed Dacron and polytetrafluoroethylene patch closure

PURPOSE

Patch angioplasty is commonly used to close the arteriotomy after carotid endarterectomy is performed. The purpose of this study was to determine whether any significant variations were present in platelet deposition for different patch sizes and materials.

METHOD

The study measured 111-indium-labeled uptake in the sheep to compare thrombus deposition for three different patch materials: autologous vein, gelatin-sealed Dacron, and polytetrafluoroethylene and for 6- and 12-mm patch widths. Platelet uptake was measured on the patch itself and on the artery wall that was opposite to the patch and that had undergone endarterectomy. Scanning electron microscopy was used to confirm the localization of the labeled platelets on the patch and on the surface that had undergone endarterectomy.

RESULTS

Although considerable variation was seen among animals, platelet accumulation was lowest in the vein patches compared with the prosthetic patches (p < 0.01), but the deposition on the gelatine-sealed Dacron was not significantly different from that on polytetrafluoroethylene patches. Platelet deposition on the artery wall that had undergone endarterectomy was considerably less than on the patch but was higher when a synthetic patch was used rather than a vein patch (p < 0.05).

CONCLUSIONS

Acute thrombus deposition after carotid endarterectomy was considerably less for vein patch closure than for synthetic patches. A 6-mm patch width caused less thrombus deposition both on the patch itself and on the artery wall compared with a 12-mm patch, but the difference was proportional to the patch width.

Carotid endarterectomy with reconstruction techniques tailored to operative findings

PURPOSE

Reconstruction techniques tailored to operative findings were applied to 466 consecutive carotid endarterectomies (CEA) performed on 408 patients over 5 years. The choice of reconstructive technique was based on the extent of the arteriotomy incision required to obtain a complete internal CEA endpoint, the ability to obtain a complete endpoint, and the quality or redundancy of the endarterectomized internal carotid artery (ICA) segment. The hypothesis was that a complete internal CEA endpoint and a tapered, smooth, nonkinked reconstruction minimize complications.

METHODS

Complete distal endpoint feathering was obtained in 437 (94%) CEA. Patch reconstruction was performed in the 429 (92%) CEA in which the arteriotomy extended distal to the ICA bulb. Before patching, 16 (3.4%) redundant endarterectomized ICA segments were shortened by transverse-eversion suture plication to prevent kinking. A saphenous vein interposition graft was used in nine (1.9%) CEA. The other 28 (6.0%) CEA had an arteriotomy that did not extend distal to the bulb and were primarily closed.

RESULTS

Two (0.4%) patients died of myocardial infarction in the hospital; one of these patients also had a stroke. Three (0.6%) patients had nonfatal strokes in the hospital. Five patients had hyperperfusion syndrome after CEA, one of which occurred without complications in the hospital. The other four occurred after discharge from the hospital. Three of these patients had a stroke, and two with strokes died. The combined 30-day mortality and nonfatal stroke rate was 2.1% for CEA and 2.4% for patients. There were no patch ruptures, false aneurysms, or ICA occlusions. Three patients had a > 50% diameter carotid artery stenosis 6 months after CEA.

CONCLUSIONS

These results support an aggressive attempt to obtain a complete or optimal ICA endpoint with reconstruction techniques based on operative findings. Recognition of patients at risk for and treatment of hyperperfusion syndrome after CEA remains a clinical challenge.