Prevention of early restenosis and thrombosis-occlusion after carotid endarterectomy by saphenous vein patch angioplasty

Selection criteria for patch angioplasty material in carotid endarterectomy

Background:

Carotid endarterectomy (CEA) with patch angioplasty has been favored due to its lower reoccurrence of restenosis compared to primary CEA. There are multiple types of patch angioplasty material available. However, selection of patch material is based on uncertain criteria. The aim of this study is to determine the ideal criteria for selecting the best patch material for CEA.

Methods:

We conducted a comprehensive literature search for studies that describe the ideal criteria for selecting patch material for CEA. We compiled all of the criteria mentioned into one table and selecting the criteria which were most frequently mentioned with a simple scoring system.

Results:

A total of 65 studies out of 784 studies were assessed for its full-text eligibility. Thus, we found 23 studies that were eligible for analysis. There are 22 ideal criteria that were mentioned in the analyzed studies. We grouped these criteria into physical characteristics, safety, contribution to hemodynamic, contribution in tissue healing, economic aspect, and ability to prevent postsurgical complication. We proposed 10 ideal criteria for guiding vascular surgeon in selecting the best patch angioplasty material.

Conclusion:

To this day, no material has been discovered which meets all ten criteria. This study’s proposed ideal criteria serve as the foundation for the creation of the best patch angioplasty material.

Literature review of primary versus patching versus eversion as carotid endarterectomy closure

BACKGROUND

Which type of closure after carotid endarterectomy (CEA), whether primary, patching, or eversion, will provide the optimal results has remained controversial. In the present study, we compared the results of randomized controlled trials (RCTs) and systematic meta-analyses of the various types of closure.

METHODS

We conducted a PubMed literature review search to find studies that had compared CEA with primary closure, CEA with patching, and/or eversion CEA (ECEA) during the previous three decades with an emphasis on RCTs, previously reported systematic meta-analyses, large multicenter observational studies (Vascular Quality Initiative data), and recent single-center large studies.

RESULTS

The results from RCTs comparing primary patching vs primary closure were as follows. Most of the randomized trials showed CEA with patching was superior to CEA with primary closure in lowering the perioperative stroke rates, stroke and death rates, carotid thrombosis rates, and late restenosis rates. These studies also showed no significant differences between the preferential use of several patch materials, including synthetic patches (polyethylene terephthalate [Dacron; DuPont, Wilmington, Del], Acuseal [Gore Medical, Flagstaff, Ariz], polytetrafluoroethylene, or pericardial patches) and vein patches (saphenous or jugular). The results from observational studies comparing patching vs primary closure were as follows. The Vascular Study Group of New England data showed that the use of patching increased from 71% to 91% (P < .001). Also, the 1-year restenosis and occlusion (P < .01) and 1-year stroke and transient ischemic attack (P < .03) rates were significantly lower statistically with patch closure. The results from the RCTs comparing ECEA vs conventional CEA (CCEA) were as follows. Several RCTs that had compared ECEA with CCEA showed equivalency of CCEA vs ECEA (level 1 evidence) with patching in the perioperative carotid thrombosis and stroke rates. At 4 years after treatment, the incidence of carotid stenosis was lower for ECEA than for primary closure (3.6% vs 9.2%; P = .01) but was comparable between patching and eversion (1.5% for patching vs 2.8% for eversion).

CONCLUSIONS

Routine carotid patching or ECEA was superior to primary closure (level 1 evidence). We found no significant differences between the preferential use of several patch materials. The rates of significant post-CEA stenosis for CEA with patching was similar to that with ECEA, and both were superior to primary closure.

A systematic review of patch angioplasty versus primary closure for carotid endarterectomy

BACKGROUND

Guidelines recommend routine patching after carotid endarterectomy (CEA) on the basis of a lower restenosis rate and presumed lower procedural stroke rate than with primary repair. Underlying evidence is based on studies performed decades ago with perioperative care that significantly differed from current standards. Recent studies raise doubt about routine patching and have suggested that a more selective approach to patch closure (PAC) might be noninferior for procedural safety and long-term stroke prevention. The objective was to review the literature on the procedural safety and perioperative stroke prevention of PAC compared with primary closure (PRC) after CEA.

METHODS

MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched from January 1966 to September 2017. Two authors independently performed the search, study selection, assessment of methodologic quality, and data extraction. Articles were eligible if they compared PAC and PRC after CEA, were published in English, included human studies, and had a full text available. Methodologic quality for nonrandomized studies was assessed using the Methodological Index for Non-Randomized Studies score; randomized controlled trials were assessed using Grading of Recommendations Assessment, Development, and Evaluation. Nonrandomized studies with a score ≤15 were excluded. The primary outcome measure was 30-day stroke risk. Secondary outcome measures were long-term restenosis (>50%) and postoperative bleeding.

RESULTS

Twenty-nine articles met the inclusion criteria, 9 randomized studies and 20 nonrandomized studies, for a total of 12,696 patients and 13,219 CEAs. Overall 30-day stroke risk was higher in the PRC group (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.2-2.9). After exclusion of nonrandomized studies, this difference was not statistically significant anymore (OR, 1.8; 95% CI, 0.8-3.9). The restenosis rate was higher after PRC (OR, 2.2; 95% CI, 1.4-3.4). There were no differences in bleeding complications. Methodologic quality of the nonrandomized studies was moderate, and seven were excluded. Quality of the evidence according to Grading of Recommendations Assessment, Development, and Evaluation was moderate for restenosis, 30-day stroke, and bleeding.

CONCLUSIONS

In this systematic review, on the basis of moderate-quality evidence, perioperative stroke rate was lower after PAC compared with PRC. The rate of restenosis was higher after PRC, although the clinical significance of this finding in terms of long-term stroke prevention remained unclear.

Reanalysis of Factors Predicting Recurrent Stenosis in a Prospective Randomized Trial of Carotid Endarterectomy Comparing Primary Closure and Patch Closure

Several factors have been implicated in the pathogenesis of recurrent carotid stenosis after carotid endarterectomy. This study examines the factors that predict recurrent stenosis in a prospective randomized trial of carotid endarterectomy comparing primary closure and patch closure. Patients undergoing 399 carotid endarterectomies were randomized into primary closures (n=135), polytetrafluoroethylene (PTFE) patch closures (n=134), and vein patch closures (n=130). Postoperative duplex ultrasounds were done at 1, 6, and 12 months, and then yearly. The mean follow-up was 41 months. Univariate analyses of potential risk factors were examined for possible association with ≥50% recurrent stenosis, and factors most associated with recurrent stenosis were examined by multivariate analyses using multiple linear regression. Primary closure had a higher incidence of recurrent stenosis (37%) than vein patch closure (13%) and PTFE patch closure (3%, p<0.001). Women with primary closure had a higher incidence of recurrent stenosis than men (49% versus 26%, p=0.008). With use of multiple linear regression models, the occurrence of ≥50% stenosis and increasing degrees of stenosis were associated most strongly with primary closure (p<0.001) and female gender (p=0.007). Carotid artery diameter, patch closure, age, coronary artery disease, or atherosclerosis risk factors (smoking, hyperlipidemia, hypertension, and diabetes mellitus) were not significantly associated with recurrent stenosis. Female gender and primary closure after carotid endarterectomy were the two factors most strongly associated with recurrence.

Long-term Comparative Outcomes of Carotid Artery Stenting Following Previous Carotid Endarterectomy vs De Novo Lesions

PURPOSE

To report the long-term outcomes of patients who underwent carotid artery stenting (CAS) for de novo carotid stenosis vs patients treated for restenosis after carotid endarterectomy (CEA).

METHODS

A retrospective review was conducted of all 385 patients (mean age 68.6±9.6 years; 231 men) who underwent 435 CAS procedures at a large tertiary care center between January 1999 and December 2013. For analysis, patients were stratified based on their lesion type [de novo (dn) vs post-CEA restenosis (res)] and subclassified by symptoms status [symptomatic (Sx) or asymptomatic (Asx)], creating 4 groups: (1) CAS-dn Asx, (2) CAS-dn Sx, (3) CAS-res Asx, and (4) CAS-res Sx. For the CAS-res group, the mean elapsed time from CEA to CAS was 72.4±63.6 months. Outcomes included target vessel reintervention (TVR) and in-stent restenosis (ISR), the latter defined by a carotid duplex ultrasound velocity >275 cm/s.

RESULTS

The main indication for initial carotid angiography with possible revascularization was severe carotid stenosis (≥70%-99% on duplex) in both CAS-dn and CAS-res groups (83.6% vs 83.7%, p=0.999). There were no significant differences in the percentage of patients with postintervention residual stenosis (<30%; 100% each arm) or complications between CAS-res vs CAS-dn: in-hospital stroke (1.4% vs 1.8%, respectively), myocardial infarction (0.9% vs 0%), or death (0.9% vs 0%). Mean follow-up was 62.4±45.6 months (median 53.5, range 1-180). Average clinical/TVR follow-up was greater for the CAS-res group (71.9±48.6 months) compared with 53.3±40.5 months for the CAS-dn group (p<0.001). Across the 4 study groups, there were no differences in freedom from ISR (p=0.174) or TVR (p=0.856). Multivariate analysis found peripheral vascular disease (PVD) as the sole ISR independent predictor [hazard ratio (HR) 1.92, 95% confidence interval (CI) 1.03 to 3.62, p=0.041], while significant predictors for TVR were age <65 years at the time of the procedure (HR 2.55, 95% CI 1.05 to 6.18, p=0.039) and PVD (HR 2.46, 95% CI 1.03 to 5.87, p=0.043).

CONCLUSION

The current study suggests that CAS is a feasible and durable therapeutic option for recurrent restenosis after CEA. Long-term outcomes were similar for patients treated for de novo lesions or post-CEA restenosis. Age and PVD appear to influence long-term CAS durability.

Prospective randomized trial of ACUSEAL versus Vascu-Guard patching in carotid endarterectomy

BACKGROUND

Multiple studies have been conducted that demonstrate the superiority of patch angioplasty over primary closure for carotid endarterectomy (CEA). Patch angioplasty with polytetrafluorethylene patches (ACUSEAL) have shown results comparable to patch angioplasty with saphenous vein and polyester patches. This is a prospective randomized study to compare the clinical outcomes of CEA using ACUSEAL versus bovine pericardium patching (Vascu-Guard).

METHODS

Two hundred patients were randomized (1:1) to either ACUSEAL or Vascu-Guard patching. Demographic data/clinical characteristics were collected. Intraoperative hemostasis times and the frequency of reexploration for neck hematoma were recorded. All patients received immediate and 1-month postoperative duplex ultrasound studies, which were repeated at 6-month intervals. A Kaplan-Meier analysis was used to estimate the risk of restenosis and the stroke-free survival rates.

RESULTS

The demographics were similar in both groups, except for a higher incidence of current smokers in the ACUSEAL group and more patients with congestive heart failure in the Vascu-Guard group (P = 0.02 and 0.03, respectively). The mean operative internal carotid artery diameter and the mean arteriotomy length were similar in both groups. The mean hemostasis time was 4.90 min for ACUSEAL patching vs. 3.09 min for Vascu-Guard (P = 0.027); however, the mean operative times were similar for both groups (ACUSEAL 2.09 hr vs. Vascu-Guard 2.16 hr, P = 0.669). The incidence of reexploration for neck hematoma was higher in the Vascu-Guard group; 6.12% vs. 1.03% (P = 0.1183). The incidence of perioperative ipsilateral neurologic events was 3.09% for ACUSEAL patching vs. 1.02% for Vascu-Guard patching (P = 0.368). The mean follow-up period was 15 months. The respective freedom from ≥70% carotid restenosis at 1, 2, and 3 years were 100%, 100%, and 100% for ACUSEAL patching vs. 100%, 98%, and 98% for Vascu-Guard patching (P = 0.2478). The ipsilateral stroke-free rates at 1, 2, and 3 years were 96% for ACUSEAL and 99% for Vascu-Guard patching.

CONCLUSIONS

Although CEA patching with ACUSEAL versus Vascu-Guard differed in hemostasis time, the frequency of reexploration for neck hematomas was more frequent in the pericardial patch group; however, only 1 patient had documented suture line bleeding and the surgical reexploration rate is not likely to be patch related. There were not any significant differences in perioperative/late neurologic events and late restenosis in the 2 groups.

Use of intraoperative duplex ultrasonography for identification and patch repair of kinking stenosis after carotid endarterectomy: a single-surgeon retrospective experience

OBJECTIVE

To provide an incidence and descriptive evaluation of kinking of the internal carotid artery (ICA) after carotid endarterectomy (CEA) in a consecutive CEA series that included the use of intraoperative duplex ultrasonography (IDUS) monitoring and to determine the effect of kink patch repair on long-term postoperative ICA restenosis.

METHODS

The electronic medical records and IDUS recordings of all CEA cases performed over a 10-year period (March 2000 to October 2010) by a single neurosurgeon were retrospectively reviewed to assess cases of kinking after CEA.

RESULTS

IDUS assisted in the identification of 27 of 285 cases (9.5%) of kinking after CEA. Kinked vessels with hemodynamically significant peak systolic velocities of ≥ 120 cm/second on IDUS (11 of 285 cases; 3.9%) were repaired using a synthetic patch. During follow-up, there were no neurologic symptoms, stroke, or death related to a cerebrovascular accident associated with kinking. The total incidence of postoperative stroke in this CEA series was 3 of 285 cases (1.1%).

CONCLUSIONS

ICA kinking stenosis after CEA was a common finding in this CEA series. Because of their unique anatomic and hemodynamic properties, the identification and assessment of kinks after CEA required the use of IDUS monitoring. A selective patch closure method for kinked vessels with peak systolic velocities of ≥ 120 cm/second identified by IDUS was effective in resolving hemodynamically significant stenosis and minimizing long-term postoperative restenosis.

Carotid Endarterectomy With Primary Closure: Analysis of Outcomes and Review of the Literature

Background:

Despite abundant published support of patch angioplasty during carotid endarterectomy (CEA), primary closure is still widely used. The reasons underlying the persistence of primary closure are not quite evident in the literature.

Objective:

To present our experience with primary closure in CEA, and provide a rationale for its persistent wide use.

Methods:

Medical records of all patients undergoing CEA by the senior author (R.F.) were retrospectively reviewed. Follow-up was supplemented with a telephone interview and completion of a structured questionnaire. A review of the current literature was performed.

Results:

From 1998 to 2010, the senior author performed 111 CEAs. Average cross-clamp time was 33 ± 11 minutes. Postoperative complications included 1 non– ST-elevation myocardial infarction and 2 strokes. No deaths, cranial-nerve deficits, or acute reocclusions were observed. After a mean follow-up of 64.6 months (7170.6 case-months), there were 3 contralateral strokes and 7 deaths. There were no ipsilateral strokes or restenoses &gt;50%. Follow-up medication compliance was 94.6% for anti-platelet agents and 91.9% for statins. The outcomes of the current study were comparable to those of the available trials comparing patch angioplasty with primary closure. A careful evaluation of the literature revealed a number of reasons potentially explaining the persistent use of patch angioplasty.

Conclusion:

In conjunction with contemporary medical management, primary closure during CEA may yield results comparable or superior to patch angioplasty. Advantages of primary closure include shorter cross-clamp times and elimination of graft-specific complications.

Carotid Artery Pseudoaneurysm After Carotid Endarterectomy: Case Series and a Review of the Literature

Background: Pseudoaneurysm (PA) after carotid endarterectomy (CEA) is a rare complication with incidence less than 1%. There is a potential for rupture, embolization, thrombosis or compression of cranial nerves. Objective: We reviewed our experience and compare it to the literature to raise awareness of this rare though serious condition. It is crucial to treat these patients early to avoid the hazardous consequences. Methods: A review of the case records of patients who had CEA at University Hospital Birmingham (UHB) NHS Foundation Trust from 1990-2007, was undertaken. Information of patients including their aetiology, presenting features, treatment and results was collected. The English-language literature was searched using PubMed database for post CEA pseudoaneurysm. Results: Five patients developed post CEA PA. This represents 0.4% of the 1200 CEA performed at our hospital in the last 18 years. The timing of their presentation varied from three days to eight months after the original operation. All had patch reconstruction after CEA. Patches were intact at exploration of the PAs. There was one death and one stroke. The literature revealed 154 carotid PAs after CEA and two cases following carotid stenting 52 of these cases had infected PA. Patients with synthetic patches have the least incidence of infection. More than 80% had open surgery and 9% had endovascular repair. Conclusion: Post CEA surveillance is necessary to detect patients with PA early. Factors that favour infection must be avoided. Endovascular repair of carotid PA should be encouraged in specialised centres.

Prospective randomized trial of ACUSEAL (Gore-Tex) vs Finesse (Hemashield) patching during carotid endarterectomy: long-term outcome

BACKGROUND

Several studies have reported that carotid endarterectomy with patch angioplasty is superior to primary closure. Conventional polytetrafluoroethylene (Gore-Tex, W. L. Gore & Associates, Flagstaff, Ariz) patching has been shown to have results similar to autogenous saphenous vein patching; however, it requires a longer hemostasis time. This study examined the long-term clinical outcome and incidence of restenosis after carotid endarterectomy using the new ACUSEAL (Gore-Tex) patching vs Hemashield Finesse (Boston Scientific Corp, Natick, Mass) patching.

METHODS

The study randomized 200 patients (1:1) undergoing carotid endarterectomy to 100 with ACUSEAL patching and 100 with Hemashield-Finesse patching. All patients underwent immediate and 1-month postoperative duplex ultrasound studies, which were repeated at 6-month intervals. Kaplan-Meier analysis was used to estimate the freedom from stroke, stroke-free survival, and the risk of restenosis for both groups.

RESULTS

The demographic and clinical characteristics, the mean operative diameter of the internal carotid artery, and the length of the arteriotomy were similar in both groups. The mean hemostasis time was 5.1 for the ACUSEAL patching vs 3.7 minutes for Finesse patching (P = .01); however, the mean operative times were similar for both groups (P = .61). The incidence of ipsilateral stroke was 2% for ACUSEAL patching (both early perioperative strokes) vs 3% for Finesse patching (2 early and 1 late stroke) at a mean follow-up of 21 months. The respective cumulative stroke-free rates at 1, 2, and 3 years were 98%, 98%, and 98% for ACUSEAL patching vs 97%, 97%, and 97% for Finesse patching (P = .7). The respective cumulative stroke-free survival rates at 1, 2, and 3 years were 97%, 92%, and 88% for ACUSEAL patching vs 96%, 96%, and 91% for Finesse patching (P = .6). The respective freedom from > or =70% carotid restenosis at 1, 2, and 3 years was 98%, 96%, and 89% for ACUSEAL patching vs 92%, 85%, and 79% for Finesse patching (P = .04).

CONCLUSIONS

Carotid endarterectomy with ACUSEAL patching and Finesse patching had similar stroke-free rates and stroke-free survival rates. The mean hemostasis time for the ACUSEAL patch was 1.4 minutes longer than that for the Finesse patch; however, the Finesse patch had higher restenosis rates than the ACUSEAL patch.

A randomized trial of synthetic patch versus direct primary closure in carotid endarterectomy

OBJECTIVE

To define whether or not direct microscopic closure with or without the use of a vascular patch is advantageous in terms of clinical outcome and late vessel occlusion rates after microsurgical carotid endarterectomy.

METHODS

Three hundred thirty-eight elective carotid endarterectomies in 315 patients were randomized to direct arteriotomy or closure with a polyester collagen-coated vascular patch. Ten procedures did not follow the randomization process because of technical difficulties and were excluded. Vessel patency (duplex ultrasound) and outcome were assessed during and immediately after surgery and at 4 and 12 months after surgery.

RESULTS

Four-month ultrasound assessment (n = 321) identified five occluded vessels: two in the patch group (n = 149) and three in the direct closure group (n = 172). Six patients in the patch group had died or were significantly disabled at 4 months, compared with five in the direct closure group. At the 12-month assessment (n = 313), eight vessels had occluded: five from the patched group (n = 146) and three from the direct closure group (n = 167). Eight patients in the patch group had died or were significantly disabled, compared with four in the direct closure group. No statistically significant difference between the two groups in terms of vessel occlusion, morbidity, or mortality was seen (P > 0.1).

CONCLUSION

No difference in vessel patency and clinical outcome has been identified after microscopic patch angioplasty and direct arteriotomy repair. The authors conclude that there is no benefit from the routine use of patch angioplasty in microscopic carotid endarterectomy.

Closure of the arteriotomy after carotid endarterectomy: Patch type is related to intraoperative microemboli and restenosis rate

OBJECTIVE

Patch closure after carotid endarterectomy (CEA) improves clinical outcome compared with primary closure. Whether there are differences in outcome between various patch materials is still not clear. The objective of this retrospective study was to investigate whether a relationship exists between the patch type and the number of microemboli as registered during CEA by transcranial Doppler imaging, the clinical outcome (transient ischemic attack and cerebrovascular accident), and the occurrence of restenosis.

METHODS

We included 319 patients who underwent CEA. Intraoperative microembolus registration was performed in 205 procedures. Microembolization was recorded during four different periods: dissection, shunting, clamp release, and wound closure. The decision to perform primary closure or to use a patch for the closure of the arteriotomy was made by the surgeon, and Dacron patches were used when venous material was insufficient. Cerebral events were recorded within the first month after CEA, and duplex scanning was performed at 3 months (n = 319) and 1 year (n = 166) after CEA. A diameter reduction of more than 70% was defined as restenosis.

RESULTS

Primary, venous, and Dacron patch closures were performed in 83 (26.0%), 171 (53.6%), and 65 (20.4%) patients, respectively. Primary closure was significantly related to sex (Dacron patch, 35 men and 30 women; venous patch, 108 men and 63 women; primary closure, 72 men and 11 women; P < .001). The occurrence of microemboli during wound closure was also related to sex (women, 2.5 +/- 0.6; men, 1.0 +/- 0.2; P = .01). Additionally, during clamp release, Dacron patches were associated with significantly more microemboli than venous patches (11.1 +/- 3.4 vs 4.0 +/- 0.9; P < .01), and this difference was also noted during wound closure (3.1 +/- 0.9 vs 1.4 +/- 0.4; P < .05). Transient ischemic attacks and minor strokes after CEA occurred in 5 (2.4%) of 205 and 6 (2.9%) of 205 procedures, respectively, and the degree of microembolization during dissection was related to adverse cerebral events (P = .003). In contrast, the type of closure was not related to immediate clinical adverse events. However, primary closure and Dacron patches were associated with an increase in the restenosis rate compared with venous patches: after 400 days, the restenosis rate for Primary closure was 11%, Dacron patch 16%, and venous patch 7% (P = .05; Kaplan-Meier estimates).

CONCLUSIONS

Microemboli are more prevalent during clamp releases and wound closure when Dacron patches are used. Additionally, the observed differences in embolization noted by patch type were mainly evident in women. However, the use of Dacron patches was not related to immediate ischemic cerebral events but was associated with a higher restenosis rate compared with venous patch closure. This suggests that venous patch closure may be preferred for CEA.

Carotid Clamping Time as a Risk Factor for Early Restenosis After Carotid Endarterectomy

OBJECTIVE

The aim of our study was to identify risk factors for early restenosis after carotid endarterectomy (CEA).

METHODS

Prospective follow-up of 497 primary CEAs was performed at 3, 6, 12 and 24 months by clinical assessment and duplex ultrasound to identify > or = 50% restenosis.

RESULTS

Early restenosis occurred in 71 (14.3%) patients. By univariate analysis high carotid clamping time (CCT) (p = 0.002) and absence of shunt use (p = 0.03) were related to early restenosis. High CCT was the only independent predictor of early restenosis in a forward stepwise logistic regression model (OR = 2.25; CI 1.2-4.1; p = 0.008).

CONCLUSIONS

Carotid clamping time may be a novel risk factor for early restenosis.

Prospective study of carotid endarterectomy with modified polytetrafluoroethylene (ACUSEAL) patching: Early and late results

OBJECTIVE

Carotid endarterectomies (CEAs) with standard polytetrafluoroethylene (PTFE) patching have been shown to have results comparable with those of autogenous vein patching; however, prolonged bleeding through needle holes in PTFE is a commonly recognized problem. This is the first study of CEA using a new hemostatic modified PTFE patch (GORE-TEX) analyzing the early and late outcomes.

METHODS

Two hundred consecutive CEAs were entered into this protocol. All patients had an immediate postoperative carotid duplex ultrasound scan that was repeated at 1 month and every 6 to 12 months thereafter. A Kaplan-Meier analysis was used to estimate the stroke-free survival and the risk of restenosis. The mean follow-up was 21 months (range, 1 to 48 months).

RESULTS

The perioperative stroke rate was 1.5% (1% ipsilateral and 0.5% contralateral, two minor strokes and one major stroke) with no perioperative mortality or perioperative carotid thrombosis. The incidence of perioperative transient ischemic attacks was 3.5% (2.5% ipsilateral and 1% contralateral). The mean hemostasis time after completion of the patching was 3 minutes, in contrast to 14 minutes for conventional PTFE (in a previous study). The rates of freedom from ipsilateral strokes at 1, 2, 3, and 4 years were 99%, 99%, 99%, and 99%, respectively. The cumulative stroke-free survival rates at 1, 2, 3, and 4 years were 98%, 96%, 93%, and 93%, respectively. The rates of freedom from > or =70% restenosis at 1, 2, 3, and 4 years were 97%, 97%, 94%, and 94%, respectively.

CONCLUSIONS

CEAs with a new modified PTFE patch are safe, have low perioperative stroke rates, are durable, and have an acceptable hemostasis time.

Prospective, randomized study of external jugular vein patch versus polytetrafluoroethylene patch during carotid endarterectomy: perioperative and long-term results

OBJECTIVES

The purpose of this study was to evaluate the relative risks and advantages of using external jugular vein (EJV) patch, compared with polytetrafluoroethylene (PTFE) patch, during carotid endarterectomy. The primary end point was the relevant neurologic complication rate (RNCR; fatal or disabling stroke) at any time during follow-up. Secondary end points included stroke-free survival, 30-day and long-term mortality, recurrent stenosis rate (> or =50%), occlusion, patch infection, aneurysm formation, and other local complications.

METHODS

The study, a prospective randomized clinical trial carried out at a single center, was divided into two 3-year phases: December 1996 to March 1999, when patients were enrolled, and March 1999 to March 2002, which was the follow-up period. Inclusion criteria included an external jugular vein suitable for patching, defined as vein diameter 3 mm or larger and absence of collateral vessels noted on preoperative color duplex ultrasound scans. Patients were prospectively randomized 1:1 to receive either the EJV (n = 80; group A) or synthetic (n = 80; group B) patch.

RESULTS

Carotid endarterectomy and patching was performed by one surgeon. At 30 months the RNCR-free rate, analyzed with the Kaplan-Meier method, was 98.7% for group A (1 ipsilateral lethal stroke) and 94.6% for group B (4 ipsilateral disabling strokes), and remained stable to 60 months. No statistical difference was observed with the log-rank test. Stroke-free survival rate was 100% for group A and 98.7% for group B at 1 year, 98.7% for group A and 93.6% for group B (1 ipsilateral minor stroke) at 30 months, and was unchanged at 60 months. Life table analysis demonstrated freedom from significant recurrent stenosis (> or =50%) of 97.5% for both groups at 6 months, 93.6% for group A and 92.2% for group B at 30 months, and 90.2% for group A and 86.7% for group B at 60 months. No statistical difference was observed with the log-rank test. In no patients was recurrent stenosis greater than 70%. No aneurysm formation was noted during follow-up.

CONCLUSIONS

We can conclude, with the power limitation of the study, that carotid endarterectomy can be safely performed with either the EJV or PTFE patch. Advantages of the EJV for carotid angioplasty include no cost for material, low risk for graft infection, and preservation of the saphenous vein.

Carotid Eversion Endarterectomy: Perioperative Outcome and Restenosis Incidence

Carotid endarterectomy (CEA) for stroke prevention can be performed with minimal perioperative mortality and morbidity rates. The type of surgical technique used is important to achieve optimal outcome from CEA. The purpose of this study was to analyze the perioperative and late results of carotid eversion endarterectomy (CEE) in more than 400 procedures. From August 1992 to December 1999, 402 primary CEEs were performed in 388 selected patients for symptomatic (235/58.4%) and asymptomatic (167/41.6%) carotid lesions. During the same period, 234 primary CEAs with patch closure were performed in 229 selected patients. All CEAs were carried out with continuous electroencephalographic monitoring for selective shunting, using deep general anesthesia. All patients underwent postoperative duplex ultrasound study and clinical follow-up at 1, 6, and 12 months and every year thereafter. The mean follow-up was 50 months (range 3-88). Main end points were perioperative stroke and death, and restenosis. Our results showed that use of the CEE procedure can reduce perioperative mortality and stroke risk rates to around zero and results in no restenosis.

A prospective, randomized study of saphenous vein patching versus synthetic patching during carotid endarterectomy

OBJECTIVE

The objective of this study was the determination of whether the choice of either autogenous saphenous vein (ASV) or synthetic material for patch angioplasty significantly influences the results after carotid endarterectomy (CEA).

METHODS

With Institutional Review Board approval, 195 patients (145 men and 50 women; mean age, 69 years) who underwent 207 CEAs were prospectively randomized to arteriotomy closure with ASV or synthetic patches from July 1996 to January 2000. One hundred and one patients (52%) were randomized to the ASV cohort, and 94 (48%) were randomized to the synthetic cohort. Aside from a slight gender imbalance (70% versus 79% male in the ASV versus the synthetic group), there were no clinically important differences in baseline demographic variables, risk factors, or surgical indications between the ASV and synthetic groups.

RESULTS

With all 207 randomized procedures on an intent-to-treat basis, there were two early (<30 days) postoperative deaths (1%). There were three perioperative strokes in the ASV cohort (3.0%) and two in the synthetic cohort (2.1%; P =.99). Two of these early strokes occurred in a subset of nine patients who received neither patch material, all after randomization but before CEA. Two patients in each group had late strokes. The cumulative freedom from stroke rate at 1 year (ASV, 94%; synthetic, 95%) was virtually identical for both cohorts. With the 125 patients who had at least one postoperative duplex scan, the incidence rate of recurrent (>or=60%) carotid stenosis was 4.8% (three of 62) for the ASV group and 6.3% (four of 63) for the synthetic group (P =.99).

CONCLUSION

No significant differences in the stroke, mortality, or restenosis rates were shown between the ASV and the synthetic cohorts. While conceding the power limitations inherent in this study, we conclude that CEA may be safely performed with similar early results with ASV or synthetic patches.

Prevention of postoperative wound haematomas and hyperperfusion following carotid endarterectomy

OBJECTIVE

To study the incidence of wound haematomas and hyperperfusion following carotid endarterectomy and the effect of changes in perioperative management.

METHODS

We undertook a prospective audit of the postoperative outcome of 300 consecutive carotid endarterectomies performed for a symptomatic stenosis of the internal carotid artery, under the care of a single consultant.

RESULTS

audit of the first 100 operations between 1990-93 resulted in 4 changes to clinical practice. These included the use of Dacron instead of vein because of 3 vein patch blowouts, invasive postoperative monitoring of blood pressure, and the use of intravenous beta-blockers to control hypertension, because of 4 hyperperfusion injuries. The use of 10F suction drains was discontinued, because they did not prevent 8 wound haematomas. The results of the second 100 cases between 1994-97 and the third 100 cases between 1998-2000 confirmed no further hyperperfusion injuries or patch blowouts (p =0.01 and 0.04 respectively). Larger 14F suction drains were reintroduced for the third series because of thirteen haematomas in the second series (p =0.09). Only 4 haematomas occurred in the third series ( p =0.05). The need for beta-blockers fell in the third series due to the introduction of local anaesthesia (p =0.0001).

CONCLUSION

The use of Dacron patches and postoperative control of hypertension has reduced the incidence of haemorrhage and hyperperfusion after carotid endarterectomy. Larger suction drains may also help.

A fifteen-year experience with carotid endarterectomy after a formal operative protocol requiring highly frequent patch angioplasty

PURPOSE

The early and late outcomes of carotid endarterectomy (CEA) following a rigid protocol of patch angioplasty or occasionally interposition bypass grafting, when the arteriotomy required to obtain a complete internal carotid end point extended distal to the bulb segment, and primary closure, when it was limited to the bulb, were studied.

METHODS

From November 1983 to August 1998, 1360 consecutive primary CEAs were performed on 1133 patients (621 men, 512 women), with a mean age of 67 years. Of these patients, 3.8% (51) had primary closure, 66.4% (903) had greater saphenous vein patch angioplasty, 28.4% (386) had synthetic (359 Dacron, 27 polytetrafluoroethylene) patch angioplasty, and 1.4% (20) had vein interposition bypass grafting procedures. Indications were transient ischemic attack in 34.7% of patients (472), stroke in 16.6% of patients (226), nonlateralizing symptoms in 10.9% of patients (148), and asymptomatic stenosis 70% or greater in 37.8% of patients (514). The mean follow-up period was 4.6 years.

RESULTS

The 30-day mortality rate was 1.0% (13 patients; 11 cardiac-related deaths, 2 strokes). The 30-day stroke rate was 1.3% (18 patients; 13 ipsilateral strokes, 5 major, 8 minor). The combined 30-day stroke and death rate was 2.1%. Four of the strokes (1 death) were caused by the hyperperfusion syndrome. The 30-day ipsilateral major stroke or mortality rate was 1.2% (16 patients). The 30-day rate of ipsilateral major stroke or death from stroke was 0.4% (5 patients). There were two synthetic and one vein patch internal carotid occlusions in 30 days. Synthetic-patched CEAs were predicted by means of Cox proportional hazards analysis to have higher risk ratios than saphenous vein-patched CEAs for early and late stroke (1. 3; 95% CI, 1.7 to 1.0; P =.04), for 50% or greater restenosis (2.4; 95% CI, 3.4 to 1.6; P <.001), and for 70% or greater restenosis (2. 5; 95% CI, 3.6 to 1.7; P <.001). The cumulative mortality rate (Kaplan-Meier) was 13% at 5 years and 31% at 10 years. The cumulative stroke rate was 7% at 5 years and 14% at 10 years. The 50% or greater restenosis rate was higher in women than in men at 5 years (9% versus 5%; P =.02, Wilcoxon), but tended to equalize later. The 50% or greater restenosis rate was higher in synthetic-patched CEAs than in saphenous vein-patched CEAs (12% versus 1% at 1 year; 17% versus 3% at 4 years; and 24% versus 10% at 8 years; P <.001 by means of log-rank and Wilcoxon). Restenosis after 5 years was more frequently located in the distal common carotid artery (13 of 20 cases). Late reoperations were more frequent and occurred earlier in synthetic-patched CEAs (eight cases at a mean of 1.6 years) than vein-patched CEAs (14 cases at a mean of 6.9 years; P =.01). No strokes and one restenosis of 50% or greater occurred in the 51 primarily closed CEAs.

CONCLUSION

Patch angioplasty reconstruction of CEAs with arteriotomies that extend distal to the carotid bulb gives excellent early and long-term outcomes. Saphenous vein-patched CEAs are superior to synthetic patched CEAs for stroke and restenosis prevention. Primary closure is safe and durable when complete end points and arteriotomies are within the carotid bulb.

The role of patch angioplasty in prevention of early recurrent carotid stenosis

The aim of this study was to determine the effect of primary closure versus patch angioplasty on the incidence of early recurrent stenosis after carotid endarterectomy in the hands of a single surgeon, and to analyze the risk factors associated with early recurrent stenosis after carotid endarterectomy. A retrospective review was performed of 178 consecutive patients who underwent 200 carotid endarterectomies-100 done consecutively with primary closure and 100 done consecutively with patch angioplasty. Of these patients, 126 qualified for analysis by having had at least 18 months of follow-up by serial duplex scanning. Of this group, the first 65 patients underwent 75 routine primary closures, while the last 61 underwent 67 routine patch angioplasties. All patients underwent a completion angiogram at the end of the case. Recurrent stenosis was defined as luminal diameter narrowing >60% on duplex scan. A multifactorial analysis was performed to analyze the effect of age, sex, tobacco use, diabetes, hypertension, peripheral vascular disease, coronary artery disease, and contralateral stenosis on recurrent stenosis. The results of this study showed that in a single surgeon's experience with carotid endarterectomy, varying only the method of closure between primary closure versus patch angioplasty, there is no statistically significant difference in the rate of early restenosis. No difference was noted in the perioperative morbidity and mortality between groups.

Carotid endarterectomy by eversion technique: its safety and durability

SUMMARY BACKGROUND DATA

The outcome of standard longitudinal carotid endarterectomy (CEA) can be measured by preservation of neurologic function with a low incidence of restenosis. Closure of the internal carotid arteriotomy with or without a patch may predispose to restenosis. Alternatively, transection of the internal carotid artery at the bulb with eversion endarterectomy allows expeditious removal of the plaque and direct visualization of the endpoint. Because the proximal internal carotid artery is anastomosed to the common carotid artery, this obviates the need for patch closure. The authors report their results with this technique in more than 2200 procedures.

METHODS

From May 1993 to March 1998, 1855 patients underwent 2249 CEAs using the eversion technique. During the same period, 410 patients had 474 CEAs by standard technique. Three hundred fifteen procedures in the eversion group and 65 procedures in the standard group were combined CEA and coronary artery bypass grafts. Most solo CEAs (97%) were performed in awake patients using regional anesthesia. Shunts were used on demand in 6% of CEAs.

RESULTS

The operative mortality rate was 1.02% (16/1575) in the solo eversion group and 2.2% (9/410) in the standard group. There were 18 permanent neurologic deficits (0.8%) in the eversion group and 11 (2.3%) in the standard group. Transient neurologic deficits occurred in 20 patients (0.9%) in the eversion group and 13 patients (2.7%) in the standard group. Of the 1855 patients, 1786 (96%) presented for duplex ultrasound follow-up. There were seven (0.3%) stenoses greater than 60% in the eversion group versus five (1.1%) in the standard group.

CONCLUSIONS

Eversion CEA can be performed safely with a low rate of stroke and death and a minimal restenosis rate in short- and long-term follow-up.

Prospective randomized trial of carotid endarterectomy with primary closure and patch angioplasty with saphenous vein, jugular vein, and polytetrafluoroethylene: long-term follow-up

PURPOSE

This study examines the long-term clinical outcome and the incidence of recurrent stenosis (> or = 50%) after carotid endarterectomy (CEA) with primary closure (PC) versus vein patch closure (VPC), saphenous (SVP), and jugular vein (JVP) and polytetrafluoroethylene patch closure (PTFE-P).

METHODS

A total of 399 CEAs were randomized into the following groups: 135 PC, 134 PTFE-P, and 130 VPC (SVP alternating with JVP). Postoperative duplex ultrasound scans were performed at 1, 6, and 12 months and every year thereafter. The mean follow-up was 30 months with a range of 1 to 62 months, and demographic characteristics were similar in all groups. Kaplan-Meier analysis was used to estimate the risk of restenosis and the stroke-free survival.

RESULTS

The incidence of ipsilateral stroke was 5% (seven of 135) for PC, 1% (one of 134) for PTFE-P, and 0% for VPC (PC vs VPC, p = 0.008; PC vs PTFE-P, p = 0.034). Seven strokes occurred in the perioperative period. All three groups had similar mortality rates. The cumulative stroke-free survival rate at 48 months was 82% for PC, 84% for PTFE-P, and 88% for VPC (p < 0.01 for PC vs PTFE-P or VPC). PC had a higher incidence of recurrent stenosis and occlusion (34%) than PTFE-P (2%) and VPC (9%) (SVP 9%, JVP 8%) (p < 0.001). PTFE-P had a lower recurrent stenosis rate than VPC (p < 0.045). Restenoses necessitating a redo CEA were also higher for PC (11%) than for PTFE-P (1%) and VPC (2%) (p < 0.001). Women with PC had a higher recurrent stenosis rate than men (46% vs 23%, p = 0.008). Kaplan-Meier analysis showed that freedom from recurrent stenosis at 48 months was 47% for PC, 84% for VPC, and 96% for PTFE-P (p < 0.001). The SVP and JVP results were comparable. The mean operative diameter of the internal carotid artery was similar in patients with or without restenosis. Significantly more late internal carotid artery dilatations occurred in the VPC group compared with the PC group.

CONCLUSIONS

Patch closure (VPC or PTFE-P) is less likely than PC to cause perioperative stroke. Patching was also superior in lowering the incidence of late recurrent stenoses, especially in women.

Patch angioplasty following carotid endarterectomy using the ipsilateral superior thyroid artery

OBJECTIVES AND DESIGN

Synthetic and saphenous vein patches, when used in the carotid territory, are disadvantaged by complications. We tested the feasibility of using a locally harvested artery, the ipsilateral superior thyroid artery (STA), as a source of patching material following carotid endarterectomy (CEA).

MATERIALS AND METHODS

Twenty-two consecutive patients (15 male) with a median age of 70 (range 53-82) years underwent CEA with an intention to use the STA for patch angioplasty. The STA was harvested via a standard carotid incision and opened longitudinally to fashion a patch.

RESULTS

Of the 22 STAs harvested, only two were rejected due to small calibre. Mean harvesting time was 12 min and there were no immediate complications. Duplex scanning has not revealed restenosis (mean peak velocity = 0.78 [range 0.45-1.16] m/s) in any patient with a median follow-up of 13 (range 3-19) months.

CONCLUSIONS

This technique is quick, convenient and obviates many of the disadvantages associated with conventional patches. Follow-up has shown the technique to be both efficacious and durable in the medium term.

Geometric dimension changes with carotid endarterectomy reconstruction

PURPOSE

The geometry of carotid endarterectomy (CEA) reconstruction is a major determinant of carotid bifurcation hemodynamics that, in turn, may play a significant role in the likelihood of early postoperative thrombosis and early and late restenosis. The purpose of this study was to measure the geometry of various types of CEA reconstructions.

METHODS

Six carotid artery diameters and lengths were measured during surgery, before and after CEA. Three reconstruction methods were used in 562 CEA procedures: a greater saphenous vein patch in 389, a synthetic patch in 157, and primary closure in 16. Veins 6 mm or more in distended diameter were trimmed before use as a patch. Synthetic patches were 8 to 11 mm in width. Patch reconstruction was used when the length of the arteriotomy required to obtain a complete distal endarterectomy end point extended beyond the internal carotid artery bulb. Saphenous vein patches were used when it was available and adequate. Neither gender nor internal carotid artery diameter was used as a criteria for the selection of the reconstruction method.

RESULTS

Before endarterectomy, the 302 male carotid arteries had 7% to 15% greater linear dimensions than the 260 female arteries (p < 0.001). Both vein and synthetic patch reconstruction produced up to 16% changes in linear dimensions except for almost doubling of the length of the internal carotid bulb. Patching made the elliptical common carotid bulb significantly more round, but the maximum diameter of curvature of the carotid bulb remained unchanged. Primary closure slightly decreased the diameter of the internal carotid bulb.

CONCLUSIONS

CEA patch reconstruction has two major effects on carotid geometry: an increase in internal carotid bulb length and a more round common carotid bulb. The former allows for a gradual transition from the terminal common carotid bulb to the uniform diameter more distal internal carotid artery. It also separates the two major causes of disturbed flow: the bifurcation and the step-down in internal carotid artery diameter. Primary closure has minimal effect on preoperative geometry.

Prospective randomized trial of carotid endarterectomy with primary closure and patch angioplasty with saphenous vein, jugular vein, and polytetrafluoroethylene: perioperative (30-day) results

PURPOSE

The early outcomes of carotid endarterectomy (CEA) with primary closure (PC) versus vein patch closure (saphenous vein [SVP] and jugular vein [JVP]) and polytetrafluoroethylene patch closure (PTFE-PC) were compared.

METHODS

Three hundred ninety-nine CEAs were randomized into the following groups: 135 PC, 134 PTFE-PC, and 130 vein patch closure (SVP alternating with JVP). Surviving patients underwent a carotid color duplex ultrasonographic scan 1 month after surgery. Demographic characteristics were similar in all groups.

RESULTS

The incidence of perioperative cerebrovascular accidents (CVAs) was 4.4% for PC, 0.8% for PTFE-PC, and 0% for vein patch closure (PC vs vein patch, p = 0.0165; PC vs all patching [vein and PTFE], p = 0.007). The perioperative CVA and reversible ischemic neurologic deficit (RIND) combined rates for all patching were superior to PC (1.5% vs 5.2%; p = 0.04). These combined rates were also superior for vein patch closure when compared with PC (0.8% vs 5.2%; p = 0.037). The mean diameter of the internal carotid artery was similar in patients who had perioperative neurologic deficits and those who did not. After 1 month of follow-up, 11.9% of the PC arteries were narrowed 50% or more in contrast to 2.3% for PTFE-PC, 3.1% for SVP, and 10.3% for JVP.

Complications resulting from saphenous vein patch graft after carotid endarterectomy

OBJECTIVE

Reducing surgical risks to the minimum in carotid endarterectomy has become crucial, especially with the results of recent clinical trials extending indications to asymptomatic patients. The use of the saphenous vein patch graft (SVPG) has been suggested to reduce early postoperative thrombosis and cerebral infarct as well as late recurrent stenosis. However, the exact risks and complications involved in this technique are not known.

METHODS

During a 23-year period (1972-1994), 2888 carotid endarterectomies with SVPG for primary carotid stenosis were performed by the Neurosurgical Cerebrovascular Service at the Mayo Clinic. The data from all patients were retrospectively analyzed, emphasizing postoperative complications related to SVPG.

RESULTS

There were five postoperative vein ruptures (0.17%), four cases of aneurysm formation, and three cases of deep infection necessitating surgical intervention. The vein patch ruptured in one male patient and four female patients (mean age, 69 yr). All ruptures occurred within 4 days of the primary operation, including two during the first 24 hours. All patients with rupture underwent emergency surgery and were found to have intact suture lines and tears in the middle of the grafts. Two patients recovered without deficits, one suffered major disability, and the other two died. Aneurysm of the patch developed in two male patients and two female patients (mean age, 71 yr). All of the patients developed painless pulsatile neck masses 1 to 9 years after the initial surgery; two also had recurrent ischemic symptoms. All of the patients with aneurysms underwent surgical correction without consequences.

CONCLUSION

Although the benefit of routine use of SVPG in carotid endarterectomy is still the focus of debate, this analysis showed that its use adds a small but definite risk of serious complications related to inherent weakness of the venous tissue. If a surgeon chooses to use a patch graft, our recommendation is for use of a synthetic material rather than vein.

Carotid endarterectomy saphenous vein patch rupture revisited: selective use on the basis of vein diameter

PURPOSE

The single major disadvantage of carotid endarterectomy (CEA) patch reconstruction with greater saphenous vein (GSV) is central patch rupture, which has a reported incidence of 0.5% to 4%. This is a prospective evaluation of the selective use of GSV for a CEA patch based on previously established vein diameter criteria.

METHODS

Between 1988 and mid-1995, 534 of 671 CEAs (80%) were reconstructed with GSVs that had a distended diameter > or = 3.5 mm. Thigh veins were used in all 252 women who underwent CEA. Of the 282 men who underwent CEA, 265 GSVs (94%) were harvested from below the knee and 17 from the thigh. During this period four thigh and 13 below-knee veins (3.2%) were rejected because the diameter was < 3.5 mm, and a synthetic patch was used instead. In 408 of the CEAs with GSV (76%) the vein rupture pressures and diameters were measured, the CEA geometry was measured, and the predicted CEA vein patch rupture pressures were calculated.

RESULTS

No GSV patches ruptured in this series. This compares favorably with three patch ruptures in 239 previous CEAs when no vein diameter criteria was used (p = 0.03). This also compares favorably with a multicenter series of 13 GSV patch ruptures (0.73%) in 1773 CEAs (p = 0.03) and with a single-center series of eight ruptures (0.47%) in 1699 CEAs (p = 0.05). GSV diameters were 4.9 +/- 0.9 mm (mean +/- 1 SD); vein rupture pressures, 3.9 +/- 1.5 atmospheres; carotid bulb major axis diameters, 12.5 +/- 1.6 mm; carotid bulb maximum diameters of curvature, 14.2 +/- 2.2 mm; and CEA patch rupture pressures, 1.3 +/- 0.6 atmospheres (range, 280 mm Hg to 4 atmospheres). CEA vein patch rupture pressure correlates positively with vein diameter (p < 0.001, slope), but there is wide variability (correlation coefficient = 0.39). The 14 CEAs (3.4%) with predicted rupture pressures < 400 mm Hg were performed with veins 3.5 to 5.5 mm in diameter (mean, 4.2 mm), and all had carotid bulb major axis diameters > 12 mm (mean, 15.3 mm). Eight of these CEAs were reconstructed with thigh veins.

CONCLUSIONS

Use of GSVs with a distended diameter > or = 3.5 mm for CEA patch reconstruction significantly reduces the probability of central patch rupture; however, a few CEAs reconstructed with veins > 3.5 mm in diameter and large carotid bulbs have predicted patch rupture pressures < 400 mm Hg. Because at times some veins will have rupture pressures lower than desirable, CEA reconstruction should be tailored to keep the carotid bulb major axis diameter < 13 mm.

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.

Does the choice of material influence early morbidity in patients undergoing carotid patch angioplasty?

BACKGROUND

This study was undertaken to determine whether the choice of material influences the early morbidity of patients undergoing carotid patch angioplasty.

METHODS

Before undergoing carotid endarterectomy, 190 patients were randomized to receive 207 patch closures with either Dacron (USCI Sauvage knitted velour) or saphenous vein harvested from the thigh.

RESULTS

One hundred seven Dacron and 100 vein patch angioplasties were performed. No significant difference was seen between the two groups in patient age, sex preoperative risk factors, or indication for operation (p > 0.25 for each variable). Among the patients undergoing Dacron patch angioplasty three strokes (two temporary and one permanent), seven episodes of bleeding requiring reoperation, and two neck wound infections requiring rehospitalization occurred. The final 32 patients with Dacron patch closures had their anticoagulation reversed and had no bleeding complications. Complications inpatients undergoing vein patch closure included one fatal perioperative stroke, two episodes of bleeding requiring reoperation including one patch rupture, and three groin infections requiring hospitalization. No significant difference was seen between the two groups in the rate of perioperative stroke (p = 0.62), episodes of bleeding (p = 0.17), or infection (p = >0.67).

CONCLUSIONS

Carotid patch angioplasty can be performed with an acceptably low complication rate with either Dacron or vein, and the choice of patch material does not clinically affect patient morbidity. However, reversal of anticoagulation is recommended to minimize bleeding complications in patients undergoing Dacron patch angioplasty.

Carotid Dacron patch angioplasty: immediate and long-term results of a prospective series

The purpose of the present study was to determine the acute clinical results associated with the performance of Dacron patch angioplasty during carotid endarterectomy, and to define the incidence of residual and recurrent carotid stenoses in patched arteries. Some 115 consecutive patients (mean age 68.0 years) underwent 119 primary carotid endarterectomy procedures in which the arteriotomy was repaired with a Dacron patch. The patients underwent duplex/occulopneumoplethysmography evaluation at 6 months after surgery, and annually thereafter. There was one (0.8%) operative death and two (1.7%) perioperative strokes. There were no immediate postoperative carotid thromboses. There were no wound or patch infections acutely, or in long-term follow-up. Thirteen patients (11%) were lost to follow-up; hence 106 arteries in 102 patients were followed for 1-65 (mean 17.8) months, including 66 arteries (62%) that have undergone serial OPG/duplex evaluation. The incidence of residual stenoses (within 3 months) was 4.5%, and that of recurrent stenoses 4.8%. The results of the study show Dacron carotid patch angioplasty to be associated with excellent clinical results, with a relatively low incidence of residual/recurrent carotid stenoses.

Expanded polytetrafluoroethylene patch angioplasty in carotid endarterectomy

PURPOSE

This study retrospectively reviewed the experience with expanded polytetrafluoroethylene (ePTFE) patches for carotid endarterectomy in 924 consecutive procedures (753 patients) during a 17-year period.

METHODS

The records of all patients who underwent ePTFE patch angioplasty for carotid artery stenosis performed by one surgeon were reviewed. The criterion for surgery was stenosis of 80% or greater. Follow-up by use of noninvasive methods was done by 6 months after operation the first year and annually thereafter. Recurrent stenosis was confirmed with angiography. Life-table analysis was used to estimate the risk of restenosis.

RESULTS

Early morbidity and mortality included six deaths (0.6%), seven nonfatal strokes (0.9%), and 19 hemorrhages. Two postoperative infections occurred. There were no important aneurysmal dilations and no late hemorrhages. With a mean follow-up of 41.4 months (range 0 to 197), recurrent stenosis necessitating reoperation developed in 28 patients (3.7%). There were two late strokes. Life-table analysis indicated a 89% probability of freedom from stenosis at 120 months.

CONCLUSIONS

In cases in which the decision to perform patch angioplasty is made at surgery, an ePTFE patch is an excellent alternative to autogenous saphenous vein, with a low rate of recurrences requiring operation and acceptable rates of perioperative and postoperative morbidity and mortality.

Eversion endarterectomy of the internal carotid artery: midterm results of a new technique

A new eversion endarterectomy technique was used in 65 internal carotid artery reconstructions in 56 patients. The original features of the technique include a complete oblique transection of the internal carotid artery distal to the lesion and eversion endarterectomy through a longitudinal incision of the common carotid and external carotid arteries. The mean age of the patients was 68.2 +/- 7.8 years. Seventy-three percent of the patients had hypertension and 45.5% had coronary heart disease. Fifty-four percent experienced neurologic symptoms (transient in 36%, reversible in 6%, and permanent in 11%). Operations were performed under general anesthesia. An indwelling shunt was inserted whenever routine stump pressure was < 50 mmHg. There were no neurologic complications but one patient died of a compression hematoma of the neck, for a combined mortality and morbidity rate of 1.5%. Arteriograms were obtained from all patients on day 5 and showed complete restoration of normal anatomy in all cases and thrombosis of the external carotid artery in one. During a mean follow-up of 27 +/- 4.7 months no strokes were observed. Follow-up duplex scans showed no hemodynamically significant restenoses. Eversion endarterectomy is a reliable alternative to other reconstruction procedures of the internal carotid artery.

A comparative study of saphenous vein, internal jugular vein, and knitted Dacron patches for carotid artery endarterectomy

To determine whether the choice of material used for patch closure following carotid artery endarterectomy (CAE) affected the immediate operative results, the early follow-up results, or the incidence of early restenosis, a retrospective study of 275 consecutive carotid endarterectomies by two vascular surgeons was performed. Among 275 primary CAEs performed between July 1991 and August 1993, 159 (57.8%) were closed with saphenous vein (SV), 25 (9.1%) with double-thickness internal jugular vein (JV), and 91 (33.1%) with knitted Dacron (KD). Primary closure was not used in any of the arteries in this series. The overall perioperative mortality rate was 1.1% and the rate of major and minor morbidity was 4.4% There were four (1.5%) perioperative strokes: two (1.3%) in the SV group, one (4.0%) in the JV group, and one (1.1%) in the KD group. Two-hundred fifty-eight (93.8%) of the 275 endarterectomies were followed postoperatively for 2 to 35 months (mean 14.4). Two-hundred nineteen (79.6%) were evaluated using duplex scans during follow-up with a mean interval of 13.7 months. Of the arteries studied, four (3.6%) in the SV group, none in the JV group, and six (8.4%) in the KD group demonstrated restenosis of > 50% at the time of follow-up (NS). In addition, one (0.9%) artery in the SV group, one (5.6%) in the JV group, and none in the KD group demonstrated complete occlusion. Retrospective analysis of the data showed no statistically significant differences in perioperative morbidity, mortality, or early postoperative restenosis whether the artery was closed with saphenous vein, jugular vein, or knitted Dacron patches. Longer follow-up is needed to determine whether rates of late restenosis and aneurysmal dilation will differ between synthetic and autologous patches.

Long-term follow-up for recurrent stenosis: a prospective randomized study of expanded polytetrafluoroethylene patch angioplasty versus primary closure after carotid endarterectomy

PURPOSE

To determine the effect of primary closure (PC) versus expanded polytetrafluoroethylene patch graft angioplasty (PGA) on the incidence of recurrent stenosis (> 50% lumen diameter narrowing) after carotid endarterectomy (CEA), 87 patients undergoing 100 consecutive CEA were prospectively randomized into two groups.

METHODS

Forty-four patients underwent 51 PC, and 43 patients underwent 49 PGA. All patients were evaluated after operation by duplex scanning at 1.5, 12, 24, and 36 months. There were no significant differences in the demographic characteristics or operative indications for CEA between the two patient groups. Complete follow-up was achieved in 86% (75/87) of the patients during the 36-month surveillance period.

RESULTS

The perioperative permanent neurologic morbidity in the PC and PGA groups was noted to be 4% and 2%, respectively (PC = 2/51 vs PGA = 1/49, p = 0.58). Three additional reversible cerebral ischemic events occurred in the postoperative period (PC = 2/51 vs PGA = 1/49, p = 0.58). Other morbidity included immediate postoperative hemorrhage requiring reexploration (1/51) in the PC group and an infected expanded polytetrafluoroethylene patch requiring removal and replacement with autogenous vein (1/49). Long-term follow-up detected a single patient with significant bilateral restenoses of his primarily closed carotid arteries. None of the patients in the PGA group had restenoses (PC = 2/51 vs 0/49, p = 0.50). In addition, no postoperative dilation of the common or internal carotid arteries or perioperative death was observed.

CONCLUSIONS

In patients undergoing CEA, these data demonstrate no significant difference in the perioperative morbidity or mortality between PC and PGA. Use of the patch did not engender patients to patch rupture or aneurysmal degeneration as previously described with vein patch angioplasty procedures. This series supports effective use of either technique to achieve minimal rates of restenosis.

Saphenous vein patch versus primary closure for carotid endarterectomy: long-term assessment of a randomized prospective study

PURPOSE

This study examines the long-term results of a randomized prospective study comparing primary versus saphenous vein patch (VP) closure after carotid endarterectomy (CEA).

METHODS

One-hundred thirty-six patients undergoing 163 CEAs over a 46-month period were prospectively randomized to VP, or primary closure. Patients with internal carotid artery diameters less than 5 mm and those requiring complex CEAs underwent obligatory vein patch (OVP). Patients were monitored with duplex scanning every 3 months for 1 year and every 6 months thereafter. All patients received aspirin.

RESULTS

There were three perioperative strokes (one in the primary group, two in the OVP group) and no perioperative deaths. Two perioperative revisions were performed within 30 days of the original CEA for residual disease. During a mean follow-up of 59 +/- 4 months, nine ipsilateral neurologic events have occurred, including two strokes and seven transient ischemic attacks. Sixteen patients had duplex evidence of recurrent stenosis, and one was associated with a stroke 36 months after CEA. Recurrence rates were similar in all groups (cumulative recurrence at 5 years: primary 7.8%, VP 14.3%, OVP 5.3%). Of the 136 patients (163 procedures), 72 (53%) (88 procedures) are alive and well, 16 (11.7%) (19 procedures) have been lost to follow-up, and 48 patients (35.3%) (56 procedures) have died. The cumulative stroke-free survival rate at 84 months was 71% for VP, 74% for OVP, and 60% for the primary group.

CONCLUSIONS

These results demonstrate that CEA is a durable procedure. The use of VP closure did not produce superior long-term results compared with the use of primary closure in this select group of patients.

Benefits of carotid patching: a prospective randomized study with long-term follow-up

A prospective study with random selection between primary closure and saphenous vein patching after carotid endarterectomy was conducted. Patients were evaluated with intravenous digital subtraction angiography during the initial postoperative period, followed by duplex scanning at 3 and 6 months, and then yearly examinations. The series consisted of 129 carotid endarterectomies, of which 62 were primary closures and 67 were patch procedures. Both groups were identical with regard to risk factors, symptoms, and postoperative control digital subtraction angiography. Restenosis was defined as a stenosis with > or = 50% diameter reduction, as assessed by duplex scanning. Of special interest was the development of restenosis along with the occurrence of cerebrovascular symptoms at long-term follow-up. The follow-up data from the 129 carotid endarterectomies are presented in a life-table analysis. The mean length of follow-up was 5 years (range 1 to 96 months). During the follow-up period 38 patients who had undergone 39 operations died (mortality rate 30%); three deaths were attributed to cerebral causes (two in-hospital deaths due to intracerebral hemorrhage and one cerebral hemorrhage after 6 months). Restenosis occurred in 25 cases (19%). This restenosis was detected in 5 of 45 men with primary closure (11%), 12 of 17 women with primary closure (70%), 7 of 49 men with patch closure (14%), and 1 of 18 women with patch closure (5.5%). The difference between patch and primary closures was found to be statistically significant (hazard ratio 0.39; 95% confidence interval 0.17 to 0.91; p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

Does routine patch angioplasty after carotid endarterectomy lessen the risk of perioperative stroke?

From 1964 through 1991 we performed primary closure of the arteriotomy in 1173 patients and patch angioplasty in 506 patients after carotid endarterectomy. The decision to patch was made at the surgeon's discretion. In general a patch was used for small arteries. In the primary closure group 32 patients (2.7%) had a perioperative stroke and in the patch angioplasty group 17 (3.4%) had a stroke. The difference (2.7% vs. 3.4%) was not significant (p < 0.5275, Fisher's exact two-tailed test). A total of 240 arteries were closed with a vein patch and 11 (4.6%) of these patients had a stroke; 266 were closed with a synthetic patch (Dacron, 211; polytetrafluoroethylene, 55) and six of the patients had a stroke (2.3%). The difference in stroke rate between the vein and synthetic patch groups (4.6% vs. 2.3%) was not significant (p < 0.2159). Patch angioplasty cannot be shown to reduce the incidence of perioperative stroke. Late carotid patency was not studied. This study supports a policy of selective patch angioplasty based on arterial size rather than patching all carotid arteries. When a patch is used, we prefer filamentous Dacron as the patch material.

Physical properties and testing methods for PTFE cardiovascular patches

Patching after endarterectomy, especially carotid artery surgery, is a common procedure to repair and close the surgical site. Both synthetic and natural materials can be used, but saphenous vein is preferred due to its greater long-term patency. In situations where it is not possible to use the saphenous vein, both Dacron and expanded polytetrafluoroethylene (ePTFE) patches have been used successfully. Expanded PTFE patches are readily available, soft and pliable, have excellent biocompatibility and do not require preclotting prior to implantation. Comparison of two types of ePTFE patches versus natural vessel show that they have more than adequate properties for their intended use.

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.

Hemodynamic effects of primary closure versus patch angioplasty of the carotid artery

This study evaluated the hemodynamic changes associated with patch angioplasty compared to primary closure of the canine carotid artery. A standard arteriotomy was closed either primarily, with a 5x28 mm expanded polytetrafluoroethylene (ePTFE) patch, or with a 10x28 mm ePTFE patch. Measurements for the primary closure group showed a systolic pressure gradient of 17 mmHg across the closure and a peak systolic velocity increase of 58% at mid-closure compared to proximal inflows. Flow turbulence increased at mid-closure in the 10 mm patch group, with the percent spectral window lowered from 0.50 to 0.36. These data show that primary vessel closure creates a mild local stenosis with flow acceleration but no flow turbulence. No significant hemodynamic disturbances are caused by a moderate sized patch; however, a large patch relative to native vessel dimensions creates marked flow disturbances throughout the cardiac cycle. As turbulence and flow separation are felt to contribute to restenosis, care should be taken in the selection of patch size when used following carotid endarterectomy.