Patch Angioplasty or Primary Closure Following Carotid Endarterectomy for Symptomatic Carotid Artery Stenosis

Objectives Guidelines recommend routine patching to prevent restenosis following carotid endarterectomy, mainly based on studies performed many years ago with different perioperative care and medical treatment compared with current standards. Aim of the present study was to compare primary closure (PRC) versus patch closure (PAC) in a contemporary cohort of patients. Methods Consecutive patients treated by carotid endarterectomy for symptomatic stenosis between January 2006 and April 2016 were retrospectively analyzed. Primary outcome was restenosis at 6 weeks and 1 year and occurrence of ipsilateral stroke. Secondary outcomes were mortality, complications, and reintervention rates. Results Five hundred carotid artery endarterectomies were performed. Fifty-nine patients were excluded because eversion endarterectomy was performed or because they were asymptomatic. PRC was performed in 349 and PAC in 92 patients. Restenosis at 6 weeks was 6.0% in the PAC group versus 3.0% in the PRC group (p = 0.200). Restenosis at 1 year was 31.6 versus 14.1%, respectively (p = 0.104). No difference was found for stroke (3.4 vs 1.1%, p = 0.319), death (1.1 vs 0.0%, p = 0.584), or other complications (1.1 vs 0.0%, p = 0.584), respectively. Conclusions It remains unclear whether routine patching should be recommended for all patients. A strategy of selective patching compared with routine patching, based on internal carotid artery diameter and other patient characteristics, deserves further investigation.

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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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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

European Journal of Vascular and Endovascular Surgery ◽

10.1016/j.ejvs.2019.09.298 ◽

2019 ◽

Vol 58 (6) ◽

pp. e747

Author(s):

Vicky Maertens ◽

Heidi Maertens ◽

Anneleen Stockman ◽

Stefanie De Buyser ◽

Cedric Coucke ◽

...

Keyword(s):

Carotid Artery ◽

Carotid Endarterectomy ◽

Primary Closure ◽

Carotid Bifurcation ◽

Closure Technique ◽

Patch Angioplasty

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Comprehensive comparison of carotid endarterectomy primary closure and patch angioplasty: A single-institution experience

Surgical Neurology International ◽

10.25259/sni_1013_2021 ◽

2022 ◽

Vol 13 ◽

pp. 1

Author(s):

Nirmeen Zagzoog ◽

Ali Elgheriani ◽

Ahmed Attar ◽

Radwan Takroni ◽

Majid Aljoghaiman ◽

...

Keyword(s):

Carotid Endarterectomy ◽

Primary Closure ◽

Retrospective Chart Review ◽

Single Institution ◽

Recurrent Stenosis ◽

Doppler Ultrasound Imaging ◽

Patch Angioplasty ◽

Comprehensive Comparison ◽

Patch Closure

Background: Carotid endarterectomy (CEA) is an effective intervention for the treatment of high-grade carotid stenosis. Technical preferences exist in the operative steps including the use patch for arteriotomy closure. The goals of this study are to compare the rate of postoperative complications and the rate of recurrent stenosis between patients undergoing primary versus patch closure during CEA. Methods: Retrospective chart review was conducted for patients who underwent CEA at single institution. Vascular surgeons mainly performed patch closure technique while neurosurgeons used primary closure. Patients’ baseline characteristics as well as intraprocedural data, periprocedural complications, and postprocedural follow-up outcomes were captured. Results: Seven hundred and thirteen charts were included for review with mean age of 70.5 years (SD = 10.4) and males representing 64.2% of the cohort. About 49% of patients underwent primary closure while 364 (51%) patients underwent patch closure. Severe stenosis was more prevalent in patients receiving patch closure (94.5% vs. 89.4%; P = 0.013). The incidence of overall complications did not differ between the two procedures (odds ratio = 1.23, 95% confidence intervals = 0.82–1.85; P = 0.353) with the most common complications being neck hematoma, strokes, and TIA. Doppler ultrasound imaging at 6 months postoperative follow-up showed evidence of recurrent stenosis in 15.7% of the primary closure patients compared to 16% in patch closure cohort. Conclusion: Both primary closure and patch closure techniques seem to have similar risk profiles and are equally robust techniques to utilize for CEA procedures.

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Carotid endarterectomy: neither shunting nor patching technique

Asian Cardiovascular and Thoracic Annals ◽

10.1177/0218492318788777 ◽

2018 ◽

Vol 26 (6) ◽

pp. 446-450 ◽

Cited By ~ 2

Author(s):

Aram Baram ◽

Goran Majeed ◽

Allaa Subhi Abdel-Majeed

Keyword(s):

Carotid Artery ◽

Carotid Endarterectomy ◽

Carotid Artery Stenosis ◽

Primary Closure ◽

Artery Stenosis ◽

Safe Procedure ◽

Total Occlusion ◽

Patch Angioplasty ◽

Bilateral Carotid

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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