Five-year Follow-up After Carotid Endarterectomy Shows Primary Closure to be an Equivalent Closure Technique Compared to Patch Angioplasty when Used in Selected Patients with Broad Carotid Artery, High Carotid Bifurcation or Occlusion of the Contralateral Carotid Artery

Introduction The role of carotid shunting in carotid endarterectomy is controversial. Many studies have concluded that patch angioplasty is preferable to primary closure, while others found that it had no value. The aim of this study was to report the results of our first series of patients undergoing carotid endarterectomy with a non-shunting technique and primary closure of the arteriotomy. Methods From October 2014 to October 2017, 63 patients with unilateral or bilateral carotid artery stenosis underwent carotid endarterectomy. There were 48 males and 15 females, the mean age was 63.16 years, and all were symptomatic. Conventional endarterectomy was performed without a shunt in all cases. All arteriotomies were closed primarily. We analysed the early and late outcomes of this procedure with at least 18 months of follow-up. Results Diabetes was the most frequent comorbidity. Most of the patients had a history of transient ischemic attack (49.2%) or stroke (44.4%). All patients had significant (moderate to severe) carotid artery stenosis. Postoperatively, 2 (3.2%) patients developed ischemic stroke, one (1.6%) suffered hypoglossal nerve injury, and one had a postoperative cervical hematoma. During follow-up, one patient developed asymptomatic total occlusion of the endartrectomized carotid artery at 18 months. Conclusion Carotid endarterectomy without shunting is a safe procedure. The short- and longer-term outcomes are not significantly inferior to those of the routine or selective shunting technique, and the rate of restenosis is not higher than that of patch angioplasty closure.

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Outcomes of Carotid Endarterectomy with Primary Closure

International Journal of Angiology ◽

10.1055/s-0037-1601053 ◽

2017 ◽

Vol 26 (02) ◽

pp. 083-088 ◽

Cited By ~ 3

Author(s):

Ivy Cheng ◽

Krishna Vyas ◽

Santhosh Velaga ◽

Daniel Davenport ◽

Sibu Saha

Keyword(s):

Carotid Endarterectomy ◽

Primary Closure ◽

Complication Rates ◽

Short Term ◽

Specific Patient ◽

Cross Clamp Time ◽

Complication Risk ◽

Duplex Imaging ◽

Patch Angioplasty

AbstractCarotid endarterectomy (CEA) reduces the risk of stroke in patients with internal carotid artery stenosis, although the optimal surgical technique is debated. The literature suggests that patch angioplasty reduces complication risk, although primary closure shortens cross-clamp time and eliminates complications associated with grafts.The objective of this study was to assess the complication rate after CEA with primary closure.Retrospective review of 240 consecutive patients between 2002 and 2010. Of these patients, 70% returned for follow-up visits for at least 2 or more years.Primary closure was used in all patients. The average cross-clamp time was 18 minutes. Complications in the immediate postoperative period within 30 days were as follows: stroke (n = 3; 1.1%), transient ischemic attack (TIA; n = 4; 1.5%), myocardial infarction (MI; n = 3; 1.1%), and death (n = 1; 0.4%). Short-term follow-up revealed eight patients who were found to have significant restenosis (>80%) by carotid duplex imaging. Two to ten year postoperative complication rates were as follows: stroke (n = 7; 4.2%), TIA (n = 7; 4.2%), amaurosis fugax (n = 1; 0.6%), MI (n = 8; 4.8%), and death (n = 28; 17%). Mortality was due to stroke or heart attack (n = 2; 1.2%), cancer (n = 7; 4.2%), and unknown causes (n = 19; 11%).This study presents our experience with complications after primary closure after CEA. In our experience, CEA is a safe and effective surgical means of preventing stroke in the short term. Well-designed prospective studies are needed to confirm specific patient characteristics in which primary closure and patch angioplasty are indicated.

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Revisiting carotid endarterectomy: Neobulb technique using external carotid artery as a patch

Vascular ◽

10.1177/17085381211052378 ◽

2021 ◽

pp. 170853812110523

Author(s):

Adalberto P Araujo ◽

Cristiane F Araujo‐Gomes ◽

Douglas Poschinger-Figueiredo ◽

Carlos Felipe S Delgado ◽

Monica R Mayall ◽

...

Keyword(s):

Carotid Artery ◽

Carotid Endarterectomy ◽

Carotid Stenosis ◽

Carotid Bifurcation ◽

External Carotid Artery ◽

External Carotid ◽

Long Term Follow Up ◽

Distal Flow

Objectives This study describes an alternative carotid bifurcation endarterectomy technique in which the external carotid artery is used as a suture patch. Methods Charts of ten patients with atherosclerotic carotid stenosis that were treated using the neobulb technique between 2002 and 2019 were reviewed. Results No major surgical adverse event was observed in the postoperative assessments. No postoperative common or internal carotid stenosis was observed in the mid- or long-term follow-up. Conclusions The neobulb technique allows carotid endarterectomy closure without a synthetic or venous patch, using the external carotid artery as an autologous patch, while preserving distal flow into the external carotid artery branches.

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Abstract 115: Is Routine Patching Necessary Following Carotid Endarterectomy (CEA)?

Arteriosclerosis Thrombosis and Vascular Biology ◽

10.1161/atvb.36.suppl_1.115 ◽

2016 ◽

Vol 36 (suppl_1) ◽

Author(s):

Nicholas J Gargiulo

Keyword(s):

Carotid Artery ◽

Carotid Endarterectomy ◽

Retrospective Review ◽

Primary Closure ◽

Perioperative Stroke ◽

Symptomatic Carotid ◽

Significant Difference ◽

Patch Closure ◽

Closure Group

Objectives: Large medicare databases and meta-analyses recommend routine patching following carotid endarterectomy (CEA). Routine patching reduces perioperative stroke, carotid thrombosis, and restenosis. This 30 year experience evaluates the long term outcome of CEA with selective patching and without routine postoperative duplex examination. Methods: An IRB-approved retrospective review of all CEAs peformed by two surgeons over a 30 year period (1984-2014). Pre-operative imaging studies, operative reports, physical findings, co-morbid conditions, and pre- and postoperative medications were evaluated. Results: Over a 30-year period, 439 CEAs were performed for symptomatic carotid disease using a selective patch technique depending on gender, internal carotid artery diameter, cardiovascular risk factors, and preoperative arteriogram. In this group of 439 patients, 17 (3.9%) had patch closure of the carotid artery and the other 422 (96.1%) had primary closure. There were 2 (0.47%) perioperative strokes in the primary closure group and 4 (0.95%) patients in this group developed symptomatic carotid restenosis at a mean follow-up of 49.5 months (range 1 to 237 months). There was 1 (5.8%) carotid thrombosis in the patch closure group who also had a perioperative stroke and was serologically positive for a hypercoagulable disorder. The 4 patients who developed symptomatic restenosis had arteriographically proven > 90% stenosis and required repeat CEA. The remaining 418 (99.0%) patients having primary closure remained neurologically asymptomatic (mean follow-up 10.3 years, range 2.5 to 17 years). There was 1 (0.23%) operative death that occurred following the induction of general anesthesia. Conclusions: In this experience, there is no statistically significant difference in restenosis in the primary closure group and selective patch group following CEA. Although this data set is a small, single center, two surgeon, retrospective review, it does not support the generally well accepted view of routine patching following CEA

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

Neurosurgery ◽

10.1227/neu.0b013e3182351de0 ◽

2011 ◽

Vol 70 (3) ◽

pp. 646-655 ◽

Cited By ~ 12

Author(s):

Georgios Zenonos ◽

Ning Lin ◽

Albert Kim ◽

Jeong Eun Kim ◽

Lance Governale ◽

...

Keyword(s):

Carotid Endarterectomy ◽

Medical Records ◽

Primary Closure ◽

Medication Compliance ◽

Senior Author ◽

Careful Evaluation ◽

Patch Angioplasty ◽

St Elevation ◽

Structured Questionnaire

Abstract 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 >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.

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

Journal of Vascular Surgery ◽

10.1016/s0741-5214(98)70353-2 ◽

1998 ◽

Vol 27 (2) ◽

pp. 222-234 ◽

Cited By ~ 131

Author(s):

Ali F. AbuRahma ◽

Patrick A. Robinson ◽

S. Saiedy ◽

Jamal H. Khan ◽

James P. Boland

Keyword(s):

Randomized Trial ◽

Carotid Endarterectomy ◽

Saphenous Vein ◽

Primary Closure ◽

Jugular Vein ◽

Prospective Randomized Trial ◽

Patch Angioplasty ◽

Long Term Follow Up

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Immediate and long-term outcomes of carotid bifurcation remodeling

Patologiya krovoobrashcheniya i kardiokhirurgiya ◽

10.21688/1681-3472-2013-1-21-24 ◽

2015 ◽

Vol 17 (1) ◽

pp. 21 ◽

Cited By ~ 1

Author(s):

A. A. Karpenko ◽

V. B. Starodubtsev ◽

P. V. Ignatenko ◽

R. A. Kuzhuget ◽

I. N. Kim ◽

...

Keyword(s):

Carotid Artery ◽

Carotid Endarterectomy ◽

Carotid Bifurcation ◽

Long Term Outcomes ◽

Long Term Follow Up

Immediate and long-term outcomes of carotid endarterectomy (CEA) performed in 363 patients at 6 months to 4 years are presented. It was found out that when using a xenopericardial patch, the occurrence of carotid artery restenosis is significantly lower if compared with the application of a PTFE patch. In comparison with classical CEA (carotid plasty with a xenopericardial patch and PTFE), eversion CEA and CEA with autoarterial bifurcation remodeling have a significantly lower frequency of restenosis (p<0,01) during long-term follow-up.

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

Journal of Vascular Surgery ◽

10.1016/s0741-5214(94)70095-8 ◽

1994 ◽

Vol 19 (2) ◽

pp. 198-205 ◽

Cited By ~ 83

Author(s):

Daniel Katz ◽

Stanley O. Snyder ◽

Raju H. Gandhi ◽

Jock R. Wheeler ◽

Roger T. Gregory ◽

...

Keyword(s):

Carotid Endarterectomy ◽

Primary Closure ◽

Randomized Study ◽

Prospective Randomized Study ◽

Expanded Polytetrafluoroethylene ◽

Patch Angioplasty ◽

Long Term Follow Up ◽

Polytetrafluoroethylene Patch

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Common Carotid Artery Imbrication as an Adjunct to Carotid Endarterectomy to Prevent Postoperative Carotid Kinking

The American Surgeon ◽

10.1177/000313480707300316 ◽

2007 ◽

Vol 73 (3) ◽

pp. 276-278

Author(s):

Juergen Falkensammer ◽

Albert G. Hakaim ◽

W. Andrew Oldenburg ◽

Todd B. Berland

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Carotid Endarterectomy ◽

Common Carotid Artery ◽

Internal Carotid ◽

Duplex Ultrasound ◽

Retrospective Chart Review ◽

Patch Angioplasty ◽

The Common

Mobilization of a tortuous carotid artery during endarterectomy may produce redundancy of the carotid artery, and kinking. We reviewed our experience with common carotid artery (CCA) imbrication as a technique to shorten the common and internal carotid artery postendarterectomy and to avoid carotid kinking. A retrospective chart review of 163 patients who underwent carotid endarterectomy by the same surgeon between August 1998 and February 2006 was performed. All patients underwent conventional endarterectomy via a longitudinal arteriotomy with an indwelling shunt and patch angioplasty. Patients undergoing concomitant carotid artery imbrication were identified. Twelve patients who underwent carotid imbrication were identified. The mean age was 74.9 ± 8.8 years. Nine patients underwent imbrication of the CCA, and in three cases, the internal carotid artery was plicated. Follow-up duplex ultrasound examinations were available for 10 individuals and mean follow-up time was 10.7 months (range, 1–58 months). There were no cases of peri- or postoperative cerebral accidents and there was no case of restenosis. CCA imbrication as an adjunct to carotid endarterectomy is a feasible technique in preventing postoperative carotid kinking.

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Eversion carotid endarterectomy with transposition of the internal carotid artery according to A.N. Kazantsev. Hospital and long-term results.

I P Pavlov Russian Medical Biological Herald ◽

10.23888/pavlovj202129173-88 ◽

2021 ◽

Vol 29 (1) ◽

pp. 73-88

Author(s):

Anton N. Kazantsev ◽

Konstantin P. Chernykh ◽

Nona E. Zarkua ◽

Artem D. Abdullaev ◽

Anastasiya V. Povtoreiko ◽

...

Keyword(s):

Myocardial Infarction ◽

Carotid Artery ◽

Internal Carotid Artery ◽

Carotid Endarterectomy ◽

Internal Carotid ◽

Hypoglossal Nerve ◽

Carotid Bifurcation ◽

Long Term Results

Aim. This study provides an analysis of the results of eversion carotid endarterectomy (CEE) with transposition of the internal carotid artery (ICA) over the hypoglossal nerve, according to A.N. Kazantsev. Materials and Methods. The given prospective open study covering the period from January 2017 to May 2020 involved 311 patients who underwent eversion CEE with transposition of ICA over the hypoglossal nerve, according to A.N. Kazantsev. Transposition was performed in the following way: after standard isolation of the carotid arteries, their compression, arteriosection, and removal of atherosclerotic plaque, ICA was extracted in the area above the hypoglossal nerve and was implanted to the same position. The condition of the patient was controlled on repeated visits to the clinic every six months. Hemodynamics in the reconstruction zone were studied using multispiral computed tomography with angiography of carotid bifurcation with 0.6 mm steps and processing the obtained results in Sim Vascular and Open Foam programs in DICON format. The follow-up period was 18.37.1 months. In case of development of restenosis, reCEE was performed with patch plasty of the reconstruction zone. For histologic examination, the restenosis area was stained by the van Gieson method. Results. In the hospital follow-up period, one case of myocardial infarction was noted that developed due to the stents thrombosis in the anterior descending artery deployed two years before. When studying the hemodynamic properties of carotid bifurcation in the postoperative period using computer modeling, in all cases, no changes or obstacles to blood flow were formed in the ICA in the area above the hypoglossal nerve. In the long-term follow-up period, two cases of lethal outcome were recorded connected with the onset of an oncological disease. In one case, due to recurrence of the pulmonary artery thromboembolism. In two cases, the cause of myocardial infarction was thrombosis/occlusion of venous anastomoses (in one patient to the circumflex artery, in the other to the right coronary artery). In four cases, repeated acute cerebrovascular accidents developed due to restenosis after CEE. In cases of significant restenosis (n=8), reCEE was performed with plasty of the reconstruction zone with a patch. The average restenosis period was 8.23.6 months. No cardiovascular complications and cases of hypoglossal nerve traumatization were identified. Intraoperatively, it was confirmed that restenosis was formed in the bifurcation zone, in front of the perimeter of the primary arteriosection. According to the results of histological examination, the main cause of all restenoses was hyperplasia of the neointima. Conclusion. The eversion CEE with the transposition of the ICA, according to A.N.Kazantsev, creates conditions for additional maneuvers in case of restenosis and implementation of reCEE. The ICAs placement over the hypoglossal nerve during primary CEE allows more confident isolation of carotid artery bifurcation from scar tissues with a zero risk of damage to the hypoglossal nerve. Such a course of the operation makes it possible to apply a clamp on the ICA and perform arteriotomy in any location without the threat of injury to the nerve structures.

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