A Prospective Randomized Study on Bilateral Carotid Endarterectomy: Patching Versus Eversion

Abstract

ObjectiveTo compare the clinical outcome and restenosis incidence of patients who underwent carotid endarterectomy with patch closure (CEAP) on one side and carotid eversion endarterectomy (CEE) on the other. Summary Background DataAlthough a few investigators have compared the results of CEAP versus CEE, no reports have compared the outcome of CEAP versus CEE in the same patient. MethodsEighty-six patients were randomly selected for sequential surgical treatment involving either CEAP/CEE or CEE/CEAP. All patients underwent postoperative duplex ultrasound study and clinical follow-up at 1, 6, and 12 months and every year thereafter. Various factors were analyzed to ascertain any association with restenosis, and Kaplan-Meier analysis was used to estimate the risk of restenosis. ResultsDemographic and clinical data were similar in the CEAP and CEE groups. The selective shunting rate was statistically higher in the CEAP group. There were no perioperative deaths. Although the incidence of perioperative ipsilateral stroke was not significant, CEAP patients had a rate of combined transient ischemic attacks and strokes that approached statistical significance. The mean follow-up was 40 months. CEAP patients had a significantly higher incidence of restenosis and combined occlusive events and restenoses. KaplanMeier analysis showed that CEE had a significantly better cumulative patency rate than CEAP and that freedom from restenoses at 24 and 36 months was 87% and 83% for CEAP and 98% and 98% for CEE, respectively. ConclusionsCEE is less likely to cause perioperative neurologic complications and restenoses than CEAP. The significantly higher rate of unilateral recurrence suggests that local factors play a more important role than systemic factors in the occurrence of restenosis.Carotid endarterectomy (CEA) is one of the few surgical procedures whose efficacy has been tested with randomized controlled clinical trials. [1][2][3][4][5][6] Controversy has remained, however, concerning the best method for arterial closure after CEA to improve perioperative stroke and internal carotid artery (ICA) occlusion rates and to reduce the incidence of early and late restenosis. A few prospective randomized studies 7-14 have demonstrated that, when data on the three principal outcomes (perioperative stroke, early ICA occlusion, and restenosis Ͼ50% at 1 year) are pooled, the statistical results strongly favor patch-plasty over primary closure. Although patch reconstruction, regardless of the type of patch material used (autologous saphenous or

Techniques in carotid artery surgery

“…In the series reported by Shah et al, 75 the rates of restenosis were close to 4 times less frequent (0.3% in the eversion CE group, and 1.1% in the conventional CE group). In a randomized trial, Ballotta et al 6 showed no late restenosis in a group of patients who had undergone eversion, compared with 4.7% in their patched group. The pooled results from randomized trials comparing eversion with conventional treatments showed a statistically significant reduction in the incidence of delayed restenosis with eversion CE.…”

Carotid Endarterectomy: Eversion Technique

“…Numerous studies have compared standard CEA plus patching with eversion once [7][8][9][10][11][12][13][14][15][16][17][18]. Regarding the total operating and ischemic time, as well as perioperative complications, first studies has favored to eversion CEA [7,8].…”

“…Namely, on the one carotid artery at the same patient, Balotta and associates performed eversion, while on another side conventional CEA [9]. Regarding early and long term results, eversion CEA has been better [10].…”

“…8). Eversion CEA, which employs a transverse arteriotomy and reimplantation of the internal carotid artery or end-to-end anastomosis between proximal and distal segments of the common carotid artery, is reported to be associated with low restenosis [7][8][9][10][11][12][13][14][15][16][17][18][19]. The false anastomotic aneurysms occurrence during the follow-up period is almost impossible [17,19].…”

Multicenter Experience on Eversion Versus Conventional Carotid Endarterectomy in Symptomatic Carotid Artery Stenosis

“…Published studies, whether from randomized [15][16][17][18][19] or singlearm trials, have included patients with symptomatic as well as asymptomatic carotid disease. 20 -24 By contrast, the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE-1) study included only symptomatic patients, randomized to carotid artery stenting or CEA with a conventional or eversion technique.…”