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Objective: In patients with symptomatic or asymptomatic severe internal carotid artery stenosis, carotid endarterectomy (CEA) has been shown to reduce risk for stroke. The optimal surgical technique remains subject of debate. In the latest European Society of Vascular Surgery (ESVS) guidelines on the management of atherosclerotic carotid disease, routine patching is preferred to routine primary closure. However, there are no RCT’s evaluating selective patching strategies. This follow-up study aimed to assess long term complication rate and restenosis after carotid endarterectomy with selective patching.
Methods: Two hundred thirteen consecutive carotid endarterectomies over a 3-year period from January 5th 2011 to December 19th 2013 were prospectively analyzed in a follow-up study over 5 years (mean 4.6, range 3.17-6.17). Patient population consisted of 141 procedures on males and 72 on females with mean age 73 years at the time of surgery (standard deviation (SD) 8.57, range 53-95). There was a follow-up of 89%. Postoperative risk factors were assessed such as hypertension, diabetes mellitus, coronary artery disease and smoking. Postoperative symptoms of cranial nerve injury, transient ischemic events, cerebrovascular events and mortality were evaluated. Duplex ultrasound was performed by a radiologist blinded to the operative technique to evaluate patency of the carotid artery after carotid endarterectomy.
Results: Primary closure was used in 110 operations, and patch angioplasty in 103 procedures (Dacron patch). Primary closure was performed when the carotid artery had a diameter above 5 mm, when there was a high carotid bifurcation or when the contralateral carotid artery was occluded. There were no significant differences among groups' baseline characteristics at the time of surgery. Primary closure was performed significantly more in male patients (P= .02). Overall complication rate was 3.76% postoperatively (1.8% after primary closure, 5.8% after patch angioplasty) and after 5 years 5.29% (2.0% after primary closure, 9.1% after patch angioplasty). There are no significant differences in results between the two groups (P= .09 and P= .05).
In four cases patients experienced symptoms of cranial nerve damage postoperatively, two in each group. In one of the two cases in each group, the patient fully recovered and the other had persistent complaints (P-value= 1). None of the patients experienced amaurosis fugax during the 5-year follow up period. In five cases a patient had an ipsilateral cerebrovascular thrombosis in the group after patch angioplasty compared to zero in the primary closure group (P-value= .02). In the group of primary closure there was a mortality of 26 patients (23.6%) compared to 26 (25.2%) patients after patch angioplasty (P-value = .70). One was caused by cerebral hyperperfusion syndrome within one month postoperative after patch angioplasty and none were caused by an ipsilateral ischemic stroke. Objective duplex ultrasound showed no significant difference comparing restenosis in both groups (P-value= .43). In twelve cases patients showed a restenosis between 50-70% (6 primary closure and 6 patch angioplasty), none of the patients had high grade restenosis of more than 70%. Patient characteristics did not show a significant effect on long term outcomes. There was a correlation between postoperative use of antihypertensive medication and long-term stroke (P-value= .006), restenosis (P-value= .01) and mortality (P-value= .003).
Conclusion: After long-term follow-up we found primary closure and patch angioplasty to be equivalent with respect to complication rate and restenosis when used in selected cases. Best medical treatment and especially the use of antihypertensive medication should be emphasized.
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2. Hertzer NR. The Current Status of Carotid Endarterectomy, Part I: Randomized Trials versus Medical Management. Ann Vasc Surg. Aug 2017;43:1-23. doi:10.1016/j.avsg.2017.04.004
3. Palkovic S, Fischer B, Wassmann H. How useful is patch angioplasty in carotid endarterectomy? Vascular. May-Jun 2004;12 (3):206. doi:10.1258/rsmvasc.12.3.206
4. Orrapin S, Benyakorn T, Siribumrungwong B, Rerkasem K. Patch angioplasty versus primary closure for carotid endarterectomy. Cochrane Database Syst Rev. Aug 3 2022;8(8): Cd000160. doi:10.1002/14651858.CD000160.pub4
5. Harrison GJ, How TV, Poole RJ, et al. Closure technique after carotid endarterectomy influences local hemodynamics. J Vasc Surg. Aug 2014;60(2):418-27. doi:10.1016/j.jvs.2014.01.069
6. Domanin M, Bissacco D, Le Van D, Vergara C. Computational fluid dynamic comparison between patch-based and primary closure techniques after carotid endarterectomy. J Vasc Surg. Mar 2018;67(3):887-897. doi:10.1016/j.jvs.2017.08.094
7. Qumsiyeh Y, O'Banion LA, Dirks R, Ali A, Daneshvar M, Siada S. Primary arterial closure after carotid endarterectomy is a safe and expeditious technique in appropriately selected patients. Am J Surg. Dec 2022;224(6):1438-1441. doi:10.1016/j.amjsurg.2022.10.009
8. Naylor R, Rantner B, Ancetti S, et al. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg. Jan 2023;65(1):7-111. doi:10.1016/j.ejvs.2022.04.011
9. Ranaboldo CJ, Barros D'Sa AA, Bell PR, Chant AD, Perry PM. Randomized controlled trial of patch angioplasty for carotid endarterectomy. The Joint Vascular Research Group. Br J Surg. Dec 1993;80(12):1528-30. doi:10.1002/bjs.1800801211
10. Bisdas T, Pichlmaier M, Bisdas S, Haverich A, Teebken OE. Early neurologic outcome after bovine pericardium versus venous patch angioplasty in 599 patients undergoing carotid endarterectomy. Vascular. May-Jun 2010;18(3):147-53. doi:10.2310/6670.2010.00022
11. Muto A, Nishibe T, Dardik H, Dardik A. Patches for carotid artery endarterectomy: current materials and prospects. J Vasc Surg. Jul 2009;50(1):206-13. doi:10.1016/j.jvs.2009.01.062
12. Vicente Jiménez S, Carrasco P, Rodriguez G, et al. Cost-effectiveness of Carotid Surgery. Ann Vasc Surg. May 2019;57:177-186. doi:10.1016/j.avsg.2018.09.013
13. Zenonos G, Lin N, Kim A, Kim JE, Governale L, Friedlander RM. Carotid endarterectomy with primary closure: analysis of outcomes and review of the literature. Neurosurgery. Mar 2012;70(3):646-54; discussion 654-5. doi:10.1227/NEU.0b013e3182351de0
14. Chung BH, Heo SH, Park YJ, Kim YW, Woo SY, Kim DI. Comparative Analysis Using Propensity Score Matching Analysis: Primary Closure versus Patch Angioplasty During Carotid Endarterectomy. Ann Vasc Surg. Jan 2020;62:166-172. doi:10.1016/j.avsg.2018.11.011
15. Cheng I, Vyas KS, Velaga S, Davenport DL, Saha SP. Outcomes of Carotid Endarterectomy with Primary Closure. Int J Angiol. Jun 2017;26(2):83-88.
16. Kapoor R, Evins AI, Marcus J, Rigante L, Kubota M, Stieg PE. Selective Patch Angioplasty and Intraoperative Shunting in Carotid Endarterectomy: A Single-Center Review of 141 Procedures. Cureus. Oct 28 2015;7(10):e367. doi:10.7759/cureus.367
17. Avgerinos ED, Chaer RA, Naddaf A, El-Shazly OM, Marone L, Makaroun MS. Primary closure after carotid endarterectomy is not inferior to other closure techniques. J Vasc Surg. Sep 2016;64(3):678-683.e1. doi:10.1016/j.jvs.2016.03.415
18. Maertens V, Maertens H, Kint M, Coucke C, Blomme Y. Complication Rate after Carotid Endarterectomy Comparing Patch Angioplasty and Primary Closure. Ann Vasc Surg. Jan 2016;30:248-52. doi:10.1016/j.avsg.2015.07.045
19. Malas M, Glebova NO, Hughes SE, et al. Effect of patching on reducing restenosis in the carotid revascularization endarterectomy versus stenting trial. Stroke. Mar 2015;46(3):757-61. doi:10.1161/strokeaha.114.007634
20. Lal BK, Beach KW, Roubin GS, et al. Restenosis after carotid artery stenting and endarterectomy: a secondary analysis of CREST, a randomised controlled trial. Lancet Neurol. Sep 2012;11(9):755-63. doi:10.1016/s1474-4422(12)70159-x
21. Hicks CW, Talbott K, Canner JK, et al. Risk of disease progression in patients with moderate asymptomatic carotid artery stenosis: implications of tobacco use and dual antiplatelet therapy. Ann Vasc Surg. Jan 2015;29(1):1-8. doi:10.1016/j.avsg.2014.02.007
22. Chongruksut W, Vaniyapong T, Rerkasem K. Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting). Cochrane Database Syst Rev. Jun 23 2014;2014(6):Cd000190. doi:10.1002/14651858.CD000190.pub3
23. Harrison GJ, Brennan JA, Naik JB, Vallabhaneni SR, Fisher RK. Patch variability following carotid endarterectomy: a survey of Great Britain and Ireland. Ann R Coll Surg Engl. Sep 2012;94(6):411-5. doi:10.1308/003588412x13373405385494
24. Eikelboom BC, Ackerstaff RG, Hoeneveld H, et al. Benefits of carotid patching: a randomized study. J Vasc Surg. Feb 1988;7(2):240-7. doi:10.1067/mva.1988.avs0070240
25. Huizing E, Vos CG, Hulsebos RG, van den Akker PJ, Borst GJ, Ünlü Ç. Patch Angioplasty or Primary Closure Following Carotid Endarterectomy for Symptomatic Carotid Artery Stenosis. Surg J (N Y). Apr 2018;4(2):e96-e101. doi:10.1055/s-0038-1655757
26. Clagett GP, Patterson CB, Fisher DF, Jr., et al. Vein patch versus primary closure for carotid endarterectomy. A randomized prospective study in a selected group of patients. J Vasc Surg. Feb 1989;9(2):213-23. doi:10.1067/mva.1989.vs0090213
27. Aburahma AF. Duplex criteria for determining ≥50% and ≥80% internal carotid artery stenosis following carotid endarterectomy with patch angioplasty. Vascular. Feb 2011;19 (1):15-20. doi:10.1258/vasc.2010.oa0245
28. Avgerinos ED, Go C, Ling J, et al. Carotid artery disease progression and related neurologic events after carotid endarterectomy. J Vasc Surg. Aug 2016;64(2):354-360. doi:10.1016/j.jvs.2016.02.026
29. Kumar R, Batchelder A, Saratzis A, et al. Restenosis after Carotid Interventions and Its Relationship with Recurrent Ipsilateral Stroke: A Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg. Jun 2017;53(6):766-775. doi:10.1016/j.ejvs.2017.02.016
30. Gorlitzer M, Heine B, Mendel H, et al. Redo surgery for carotid artery stenosis: when and how? Cardiovasc Surg. Aug 2000;8(5):366-71. doi:10.1016/s0967-2109(00)00030-2
31. De Borst GJ, Moll F. Biology and treatment of recurrent carotid stenosis. J Cardiovasc Surg (Torino). Feb 2012;53(1 Suppl 1):27-34.
32. Mannheim D, Weller B, Vahadim E, Karmeli R. Carotid endarterectomy with a polyurethane patch versus primary closure: a prospective randomized study. J Vasc Surg. Mar 2005;41(3):403-7; discussion 407-8. doi:10.1016/j.jvs.2004.11.036
33. De Letter JA, Moll FL, Welten RJ, et al. Benefits of carotid patching: a prospective randomized study with long-term follow-up. Ann Vasc Surg. Jan 1994;8(1):54-8. doi:10.1007/bf02133406
34. Rerkasem K, Gallagher PJ, Grimble RF, Calder PC, Shearman CP. Sex difference in composition of plaques of patients undergoing carotid endarterectomy. Vascular. Mar-Apr 2010;18(2):77-81. doi:10.2310/6670.2010.00008
35. Lazarides MK, Christaina E, Argyriou C, Georgakarakos E, Tripsianis G, Georgiadis GS. Editor's Choice - Network Meta-Analysis of Carotid Endarterectomy Closure Techniques. Eur J Vasc Endovasc Surg. Feb 2021;61(2):181-190. doi:10.1016/j.ejvs.2020.10.009
36. Katano H, Mase M, Nishikawa Y, Yamada H, Yamada K. Analysis of Recurrent Stenosis After Carotid Endarterectomy Featuring Primary Plaque Calcification. Neurosurgery. Jun 1 2017;80(6):863-870. doi:10.1093/neuros/nyw119
37. Perler BA. The effect of statin medications on perioperative and long-term outcomes following carotid endarterectomy or stenting. Semin Vasc Surg. Dec 2007;20(4):252-8. doi:10.1053/j.semvascsurg.2007.10.008
38. Tyson AC, Parikh S, Singh K, Zia S, Deitch JS, Schor JA. Routine Postoperative Cardiac Testing is Unnecessary after Carotid Endarterectomy. Ann Vasc Surg. Aug 2019;59:12-15. doi:10.1016/j.avsg.2018.11.028
39. Gasior SA, O'Donnell JPM, Davey M, et al. Optimal Management of Asymptomatic Carotid Artery Stenosis: A Systematic Review and Network Meta-Analysis. Eur J Vasc Endovasc Surg. May 2023;65(5):690-699. doi:10.1016/j.ejvs.2023.01.020
40. Naylor AR. Medical treatment strategies to reduce perioperative morbidity and mortality after carotid surgery. Semin Vasc Surg. Mar 2017;30(1):17-24. doi:10.1053/j.semvascsurg.2017.04.006
41. Jonsson M, Hammar K, Lindberg M, et al. Editor's Choice - Nationwide Outcome Analysis of Primary Carotid Endarterectomy in Symptomatic Patients Depending on Closure Technique and Patch Type. Eur J Vasc Endovasc Surg. Apr 2023;65(4):467-473. doi:10.1016/j.ejvs.2022.12.033
42. Hause S, Schönefuß R, Assmann A, et al. Editor's Choice - Relevance of Infarct Size, Timing of Surgery, and Peri-operative Management for Non-ischaemic Cerebral Complications After Carotid Endarterectomy. Eur J Vasc Endovasc Surg. Feb 2022;63(2):268-274. doi:10.1016/j.ejvs.2021.09.044
43. Huo Y, Li J, Qin X, et al. Efficacy of folic acid therapy in primary prevention of stroke among adults with hypertension in China: the CSPPT randomized clinical trial. Jama. Apr 7 2015;313(13):1325-35. doi:10.1001/jama.2015.2274
44. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. Bmj. May 19 2009;338:b1665. doi:10.1136/bmj.b1665
45. Boysen G, Sørensen PS, Juhler M, et al. Danish very-low-dose aspirin after carotid endarterectomy trial. Stroke. Oct 1988;19(10): 1211-5. doi:10.1161/01.str.19.10.1211
46. Lindblad B, Persson NH, Takolander R, Bergqvist D. Does low-dose acetylsalicylic acid prevent stroke after carotid surgery? A double-blind, placebo-controlled randomized trial. Stroke. Aug 1993;24(8):1125-8. doi:10.1161/01.str.24.8.1125
47. Kretschmer G, Pratschner T, Prager M, et al. Antiplatelet treatment prolongs survival after carotid bifurcation endarterectomy. Analysis of the clinical series followed by a controlled trial. Ann Surg. Mar 1990;211(3):317-22. doi:10.1097/00000658-199003000-00002
48. Krafcik BM, Farber A, Eberhardt RT, et al. Preoperative Antiplatelet and Statin Use Does Not Affect Outcomes after Carotid Endarterectomy. Ann Vasc Surg. Jan 2018;46: 43-52. doi:10.1016/j.avsg.2017.10.002
49. Cheng SF, Richards T, Gregson J, Brown MM, de Borst GJ, Bonati LH. Long Term Restenosis Rate After Carotid Endarterectomy: Comparison of Three Surgical Techniques and Intra-Operative Shunt Use. Eur J Vasc Endovasc Surg. Oct 2021;62(4):513-521. doi:10.1016/j.ejvs.2021.06.028
50. Frericks H, Kievit J, van Baalen JM, van Bockel JH. Carotid recurrent stenosis and risk of ipsilateral stroke: a systematic review of the literature. Stroke. Jan 1998;29(1):244-50. doi:10.1161/01.str.29.1.244