Patches of different types for carotid patch angioplasty

Patches of different types for carotid patch angioplasty

BACKGROUND

Extracranial carotid artery stenosis is the major cause of stroke, which can lead to disability and mortality. Carotid endarterectomy (CEA) with carotid patch angioplasty is the most popular technique for reducing the risk of stroke. Patch material may be made from an autologous vein, bovine pericardium, or synthetic material including polytetrafluoroethylene (PTFE), Dacron, polyurethane, and polyester. This is an update of a review that was first published in 1996 and was last updated in 2010.

OBJECTIVES

To assess the safety and efficacy of different types of patch materials used in carotid patch angioplasty. The primary hypothesis was that a synthetic material was associated with lower risk of patch rupture versus venous patches, but that venous patches were associated with lower risk of perioperative stroke and early or late infection, or both.

SEARCH METHODS

We searched the Cochrane Stroke Group trials register (last searched 25 May 2020); the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 4), in the Cochrane Library; MEDLINE (1966 to 25 May 2020); Embase (1980 to 25 May 2020); the Index to Scientific and Technical Proceedings (1980 to 2019); the Web of Science Core Collection; ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) portal. We handsearched relevant journals and conference proceedings, checked reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised and quasi-randomised trials (RCTs) comparing one type of carotid patch with another for CEA.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility, risk of bias, and trial quality; extracted data; and determined the quality of evidence using the GRADE approach. Outcomes, for example, perioperative ipsilateral stroke and long-term ipsilateral stroke (at least one year), were collected and analysed.

MAIN RESULTS

We included 14 trials involving a total of 2278 CEAs with patch closure operations: seven trials compared vein closure with PTFE closure, five compared Dacron grafts with other synthetic materials, and two compared bovine pericardium with other synthetic materials. In most trials, a patient could be randomised twice and could have each carotid artery randomised to different treatment groups. Synthetic patch compared with vein patch angioplasty Vein patch may have little to no difference in effect on perioperative ipsilateral stroke between synthetic versus vein materials, but the evidence is very uncertain (odds ratio (OR) 2.05, 95% confidence interval (CI) 0.66 to 6.38; 5 studies, 797 participants; very low-quality evidence). Vein patch may have little to no difference in effect on long-term ipsilateral stroke between synthetic versus vein materials, but the evidence is very uncertain (OR 1.45, 95% CI 0.69 to 3.07; P = 0.33; 4 studies, 776 participants; very low-quality evidence). Vein patch may increase pseudoaneurysm formation when compared with synthetic patch, but the evidence is very uncertain (OR 0.09, 95% CI 0.02 to 0.49; 4 studies, 776 participants; very low-quality evidence). However, the numbers involved were small. Dacron patch compared with other synthetic patch angioplasty Dacron versus PTFE patch materials  PTFE patch may reduce the risk of perioperative ipsilateral stroke (OR 3.35, 95% CI 0.19 to 59.06; 2 studies, 400 participants; very low-quality evidence). PTFE patch may reduce the risk of long-term ipsilateral stroke (OR 1.52, 95% CI 0.25 to 9.27; 1 study, 200 participants; very low-quality evidence). Dacron may result in an increase in perioperative combined stroke and transient ischaemic attack (TIA) (OR 4.41 95% CI 1.20 to 16.14; 1 study, 200 participants; low-quality evidence) when compared with PTFE. Early arterial re-stenosis or occlusion (within 30 days) was also higher for Dacron patches. During follow-up for longer than one year, more 'any strokes' (OR 10.58, 95% CI 1.34 to 83.43; 2 studies, 304 participants; low-quality evidence) and stroke/death (OR 6.06, 95% CI 1.31 to 28.07; 1 study, 200 participants; low-quality evidence) were reported with Dacron patch closure, although numbers of outcome events were small. Dacron patch may increase the risk of re-stenosis when compared with other synthetic materials (especially with PTFE), but the evidence is very uncertain (OR 3.73, 95% CI 0.71 to 19.65; 3 studies, 490 participants; low-quality evidence). Bovine pericardium patch compared with other synthetic patch angioplasty Bovine pericardium versus PTFE patch materials  Evidence suggests that bovine pericardium patch results in a reduction in long-term ipsilateral stroke (OR 4.17, 95% CI 0.46 to 38.02; 1 study, 195 participants; low-quality evidence). Bovine pericardial patch may reduce the risk of perioperative fatal stroke, death, and infection compared to synthetic material (OR 5.16, 95% CI 0.24 to 108.83; 2 studies, 290 participants; low-quality evidence for PTFE, and low-quality evidence for Dacron; OR 4.39, 95% CI 0.48 to 39.95; 2 studies, 290 participants; low-quality evidence for PTFE, and low-quality evidence for Dacron; OR 7.30, 95% CI 0.37 to 143.16; 1 study, 195 participants; low-quality evidence, respectively), but the numbers of outcomes were small. The evidence is very uncertain about effects of the patch on infection outcomes.

AUTHORS' CONCLUSIONS

The number of outcome events is too small to allow conclusions, and more trial data are required to establish whether any differences do exist. Nevertheless, there is little to no difference in effect on perioperative and long-term ipsilateral stroke between vein and any synthetic patch material. Some evidence indicates that other synthetic patches (e.g. PTFE) may be superior to Dacron grafts in terms of perioperative stroke and TIA rates, and both early and late arterial re-stenosis and occlusion. Pseudoaneurysm formation may be more common after use of a vein patch than after use of a synthetic patch. Bovine pericardial patch, which is an acellular xenograft material, may reduce the risk of perioperative fatal stroke, death, and infection compared to other synthetic patches. Further large RCTs are required before definitive conclusions can be reached.

Right carotid-cutaneous fistula and right carotid pseudoaneurysm formation secondary to a chronically infected polyethylene terephthalate patch

Carotid endarterectomy (CEA) remains the treatment for significant carotid stenosis and stroke prevention. Approximately 100,000 CEAs are performed in the United States every year. Randomized trials have demonstrated an advantage of patch carotid angioplasty over primary closure. Complications from patches include thrombosis, transient ischemic attack, stroke, restenosis, pseudoaneurysm (PA), and infection. PA after CEA is rare, with a reported average of 0.37% of cases. We describe an unusual case of PA after polyethylene terephthalate (PTFE) patching for CEA. An 88-year-old female with Alzheimer's disease living in a nursing facility with a history of skin cancer on her right chest developed a new area of intermittent brisk bleeding on her right neck which was initially believed to be related to her skin cancer. She had a remote history of right CEA with a PTFE patch approximately a decade ago. A computed tomography angiograph-head-and-neck with showed a partially thrombosed PA in the region of her right common carotid artery bifurcation with a tract containing gas and fluid extending to the skin surface suspicious for a partially thrombosed, leaking PA. She was taken urgently to the operating room on broad-spectrum antibiotics where we performed a right neck exploration, ligation of a bleeding carotid PA by ligation of the right common, internal, and external carotid arteries, explantation of a chronically infected polyethylene terephthalate patch, and closure with a sternocleidomastoid advanced flap with multilayered closure. She was discharged to her nursing facility with 6 weeks of ceftriaxone intravenous (IV) and metronidazole IV through a peripherally inserted central catheter (PICC) line with no neurological sequelae.

Comparative Review of the Treatment Methodologies of Carotid Stenosis

The treatment of carotid stenosis entails three methodologies, namely, medical management, carotid angioplasty and stenting (CAS), as well as carotid endarterectomy (CEA). The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) have shown that symptomatic carotid stenosis greater than 70% is best treated with CEA. In asymptomatic patients with carotid stenosis greater than 60%, CEA was more beneficial than treatment with aspirin alone according to the Asymptomatic Carotid Atherosclerosis (ACAS) and Asymptomatic Carotid Stenosis Trial (ACST) trials. When CAS is compared with CEA, the CREST resulted in similar rates of ipsilateral stroke and death rates regardless of symptoms. However, CAS not only increased adverse effects in women, it also amplified stroke rates and death in elderly patients compared with CEA. CAS can maximize its utility in treating focal restenosis after CEA and patients with overwhelming cardiac risk or prior neck irradiation. When performing CEA, using a patch was equated to a more durable result than primary closure, whereas eversion technique is a new methodology deserving a spotlight. Comparing the three major treatment strategies of carotid stenosis has intrinsic drawbacks, as most trials are outdated and they vary in their premises, definitions, and study designs. With the newly codified best medical management including antiplatelet therapies with aspirin and clopidogrel, statin, antihypertensive agents, strict diabetes control, smoking cessation, and life style change, the current trials may demonstrate that asymptomatic carotid stenosis is best treated with best medical therapy. The ongoing trials will illuminate and reshape the treatment paradigm for symptomatic and asymptomatic carotid stenosis.

Management of extracranial carotid artery disease

Stroke is the third leading cause of death in developed nations. Up to 88% of strokes are ischemic in nature. Extracranial carotid artery atherosclerotic disease is the third leading cause of ischemic stroke in the general population and the second most common nontraumatic cause among adults younger than 45 years. This article provides comprehensive, evidence-based recommendations for the management of extracranial atherosclerotic disease, including imaging for screening and diagnosis, medical management, and interventional management.

Systematic review of randomized controlled trials of different types of patch materials during carotid endarterectomy

Background and Purpose

Carotid endarterectomy (CEA) with patch angioplasty produces greater results than with primary closure; however, there remains uncertainty on the optimal patch material in CEA. A systematic review of randomized controlled trials (RCTs) was performed to evaluate the effect of angioplasty using venous patch versus synthetic patch material, and Dacron patch versus polytetrafluoroethelene (PTFE) patch material during CEA.

Methods

A multiple electronic health database screening was performed including the Cochrane library, Pubmed, Ovid, EMBASE and Google Scholar on all randomized controlled trials (RCTs) published before November 2012 that compared the outcomes of patients undergoing CEA with venous patch versus synthetic patch. RCTs were included if they compared carotid patch angioplasty with autologus venous patch versus synthetic patch material, or compared one type of synthetic patch with another.

Results

Thirteen RCTs were identified. Ten trials, involving 1946 CEAs, compared venous patch with synthetic patch materials. Two trials, involving 400 CEAs in 380 patients, compared Dacron patch with PTFE patch. The hemostasis time in CEA with PTFE patch was significantly longer than with venous patch (P<0.0001), and longer than with Dacron patch (P<0.0001). There was no significant difference of mortality rate, stroke rate, restenosis, and operative time in CEA with venous patch versus synthetic patch material, or in CEA with Dacron patch versus PTFE patch (all P>0.05). One RCT of 95 CEAs in 92 patients compared bovine pericardium with Dacron patch, and demonstrated a statistically significant decrease in intraoperative suture line bleeding with bovine pericardium compared with Dacron patch (P<0.001).

Conclusions

The hemostasis time in CEA with PTFE patch was longer than with venous patch or Dacron patch. The overall perioperative and long-term mortality rate, stroke rate, restenosis, and operative time were similar when using venous patch versus synthetic patch material or Dacron patch versus PTFE patch material during CEA. More data are required to clarify differences between different patch materials.

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.

Comparative analysis of the biaxial mechanical behavior of carotid wall tissue and biological and synthetic materials used for carotid patch angioplasty

Patch angioplasty is the most common technique used for the performance of carotid endarterectomy. A large number of patching materials are available for use while new materials are being continuously developed. Surprisingly little is known about the mechanical properties of these materials and how these properties compare with those of the carotid artery wall. Mismatch of the mechanical properties can produce mechanical and hemodynamic effects that may compromise the long-term patency of the endarterectomized arterial segment. The aim of this paper was to systematically evaluate and compare the biaxial mechanical behavior of the most commonly used patching materials. We compared PTFE (n  =  1), Dacron (n  =  2), bovine pericardium (n  =  10), autogenous greater saphenous vein (n  =  10), and autogenous external jugular vein (n  =  9) with the wall of the common carotid artery (n  =  18). All patching materials were found to be significantly stiffer than the carotid wall in both the longitudinal and circumferential directions. Synthetic patches demonstrated the most mismatch in stiffness values and vein patches the least mismatch in stiffness values compared to those of the native carotid artery. All biological materials, including the carotid artery, demonstrated substantial nonlinearity, anisotropy, and variability; however, the behavior of biological and biologically-derived patches was both qualitatively and quantitatively different from the behavior of the carotid wall. The majority of carotid arteries tested were stiffer in the circumferential direction, while the opposite anisotropy was observed for all types of vein patches and bovine pericardium. The rates of increase in the nonlinear stiffness over the physiological stress range were also different for the carotid and patching materials. Several carotid wall samples exhibited reverse anisotropy compared to the average behavior of the carotid tissue. A similar characteristic was observed for two of 19 vein patches. The obtained results quantify, for the first time, significant mechanical dissimilarity of the currently available patching materials and the carotid artery. The results can be used as guidance for designing more efficient patches with mechanical properties resembling those of the carotid wall. The presented systematic comparative mechanical analysis of the existing patching materials provides valuable information for patch selection in the daily practice of carotid surgery and can be used in future clinical studies comparing the efficacy of different patches in the performance of carotid endarterectomy.

Restenosis after microsurgical non-patch carotid endarterectomy in 586 patients

Background

Carotid endarterectomy (CEA) reduces the risk of stroke in patients with symptomatic (>50%) and asymptomatic (>60%) carotid artery stenosis. Here we report the midterm results of a microsurgical non-patch technique and compare these findings to those in the literature.

Methods

From 1998 to 2009 we treated 586 consecutive patients with CEA. CEA was performed, under general anesthesia, with a surgical microscope using a non-patch technique. Somatosensory evoked potential and transcranial Doppler were continuously monitored. Cross-clamping was performed under EEG burst suppression and adaptive blood pressure increase. Follow-up was performed by an independent neurologist. Mortality at 30 days and morbidity such as major and minor stroke, peripheral nerve palsy, hematoma and cardiac complications were recorded. The restenosis rate was assessed using duplex sonography 1 year after surgery.

Results

A total of 439 (75%) patients had symptomatic and 147 (25%) asymptomatic stenosis; 49.7% of the stenoses were on the right-side. Major perioperative strokes occurred in five (0.9%) patients [n = 4 (0.9%) symptomatic; n = 1 (0.7%) asymptomatic patients]. Minor stroke was recorded in six (1%) patients [n = 4 (0.9%) symptomatic; n = 2 (1.3%) asymptomatic patients]. Two patients with symptomatic stenoses died within 1 month after surgery. Nine patients (1.5%) had reversible peripheral nerve palsies, and nine patients (1.5%) suffered a perioperative myocardial infarction. High-grade (>70%) restenosis at 1 year was observed in 19 (3.2%) patients [n = 12 (2.7%) symptomatic; n = 7 (4.7%) asymptomatic patients].

Conclusions

The midterm rate of restenosis was low when using a microscope-assisted non-patch endarterectomy technique. The 30-day morbidity and mortality rate was comparable or lower than those in recently published surgical series.

Restenosis after carotid endarterectomy in a multicenter regional registry

BACKGROUND

Level I evidence shows conventional carotid endarterectomy (CEA) with patch angioplasty results in lower rates of restenosis. However, whether this information has affected practice patterns and outcomes in real-world vascular surgery settings is unclear.

METHODS

Within the Vascular Study Group of New England (VSGNE), we studied 2981 patients undergoing 2981 first-time CEAs between January 1, 2003, and June 31, 2008. Rates of restenosis (defined by duplex ultrasound imaging at the 1-year follow-up) were estimated using life-table analysis. Cox proportional hazards models were used to identify multivariable predictors of postoperative restenosis ≤ 1 year.

RESULTS

Across 58 surgeons and 11 hospitals, we studied 2611 conventional CEAs (88% of all CEAs) and 370 eversion CEAs (12% of all CEAs). Median follow-up was 12.8 months (range, 1-35 months). The proportion of conventional CEAs performed with patching increased from 87% to 96% (P < .001) between 2003 and 2008, whereas eversion CEA declined from 18% to 5% (P < .001). Restenosis occurred in 303 patients (10%); by life-table analysis, the restenosis rate at 1 year was 6.2% (95% confidence interval [CI], 4.7%-6.8%). Restenoses were most commonly noncritical: 50%-79% restenosis in 7.9%, 80%-99% restenosis in 1.7%, and occlusion in 0.5%. Univariate analyses showed significant differences in 80% to 100% restenosis by procedure type (2% in conventional CEA, 6% in eversion CEA, P < .002), the year of procedure (3.2% in 2003, 0% in 2008; P < .03), and use of patching in conventional CEA (2.9% no patch, 1% with patch; P < .008). By multivariable analysis, absence of patching (hazard ratio [HR], 3.2; 95% CI, 1.5-7.0), contralateral internal carotid artery stenosis > 80% (HR, 4.1; 95% CI, 1.4-11.5), and dialysis dependence (HR, 3.5; 95% CI, 1.2-9.8) were independently associated with a higher risk of an 80% to 100% restenosis. Of the 51 patients with 80% to 99% restenosis, 14 underwent reintervention ≤ 1 year, comprising 4 reoperations and 10 carotid artery stent procedures. Of the 15 patients with a carotid occlusion ≤ 1 year, transient ischemic attacks occurred in 2 and a disabling stroke in 1.

CONCLUSIONS

In our region, restenosis after CEA, especially clinically significant restenosis ≤ 1 year after surgery, decreased slightly over time. This improvement in outcome was associated with several factors, including an increase in patching after conventional CEA, a process of care that was studied and encouraged within our vascular study group. These results highlight the utility of regional quality-improvement efforts in improving outcomes in vascular surgery.

Patches of different types for carotid patch angioplasty

BACKGROUND

Carotid patches for carotid endarterectomy may be made from an autologous vein or synthetic material.

OBJECTIVES

To assess the safety and efficacy of different materials for carotid patch angioplasty.

SEARCH STRATEGY

We searched the Cochrane Stroke Group trials register (last searched 3 August 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2009), MEDLINE (1966 to November 2008), EMBASE (1980 to November 2008) and Index to Scientific and Technical Proceedings (1980 to 2008). We handsearched relevant journals and conference proceedings, checked reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing one type of carotid patch with another for carotid endarterectomy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility, trial quality, and extracted data.

MAIN RESULTS

We included 13 trials involving a total of 2083 operations; seven trials compared vein closure with PTFE closure, and six compared Dacron grafts with other synthetic materials. In most trials a patient could be randomised twice and have each carotid artery randomised to different treatment groups. There were no significant differences in the outcomes between vein patches and synthetic materials apart from pseudoaneurysms where there were fewer associated with synthetic patches than vein patches (odds ratio (OR) 0.09, 95% confidence interval (CI) 0.02 to 0.49). However, the numbers involved were small and the clinical significance of this finding is uncertain. Compared to other synthetic patches, Dacron was associated with a higher risk of: perioperative combined stroke and transient ischaemic attack (P = 0.03); restenosis at 30 days (P = 0.004); perioperative stroke (P = 0.07) and perioperative carotid thrombosis (P = 0.1). During follow-up for more than one year, there were also significantly more strokes (P = 0.03), stroke/death (P = 0.02) and arterial restenoses (P < 0.0001) with Dacron but the numbers of outcomes were small and the significance of this finding is uncertain.

AUTHORS' CONCLUSIONS

The number of outcome events is too small to allow reliable conclusions to be drawn and more trial data are required to establish whether any differences do exist. Nevertheless, there is some evidence that other synthetic (e.g. PTFE) patches may be superior to collagen impregnated Dacron grafts in terms of perioperative stroke rates and restenosis. Pseudoaneurysm formation may be more common after use of a vein patch compared with a synthetic patch.

Patch angioplasty versus primary closure for carotid endarterectomy

BACKGROUND

Carotid patch angioplasty (with either a venous or a synthetic patch) may reduce the risk of carotid artery restenosis and subsequent ischaemic stroke. This is an update of a Cochrane Review originally published in 1995 and previously updated in 2004.

OBJECTIVES

To assess the safety and efficacy of routine or selective carotid patch angioplasty compared to carotid endarterectomy with primary closure.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched 5 May 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2009), MEDLINE (1966 to November 2008), EMBASE (1980 to November 2008) and Index to Scientific and Technical Proceedings (1980 to November 2008). We handsearched journals and conference proceedings, checked reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing carotid patch angioplasty with primary closure in any patients undergoing carotid endarterectomy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility, trial quality and extracted data.

MAIN RESULTS

We included 10 trials involving 1967 patients undergoing 2157 operations. The quality of trials was generally poor. Follow up varied from hospital discharge to five years. Carotid patch angioplasty was associated with a reduction in the risk of ipsilateral stroke during the perioperative period (odds ratio (OR) 0.31, 95% confidence interval (CI) 0.15 to 0.63, P = 0.001) and long-term follow up (OR 0.32, 95%CI 0.16 to 0.63, P = 0.001). It was also associated with a reduced risk of perioperative arterial occlusion (OR 0.18, 95% CI 0.08 to 0.41, P < 0.0001), and decreased restenosis during long-term follow up in eight trials (OR 0.24, 95% CI 0.17 to 0.34, P < 0.00001). These results are more certain than those of the previous review since the number of operations and events have increased. However, the sample sizes are still relatively small, data were not available from all trials, and there was significant loss to follow up. Very few arterial complications, including haemorrhage, infection, cranial nerve palsies and pseudo-aneurysm formation were recorded with either patch or primary closure. No significant correlation was found between use of patch angioplasty and the risk of either perioperative or long-term all-cause death rates.

AUTHORS' CONCLUSIONS

Limited evidence suggests that carotid patch angioplasty may reduce the risk of perioperative arterial occlusion and restenosis. It would appear to reduce the risk of ipsilateral stroke and there is a non significant trend towards a reduction in perioperative any stroke rate and all-cause case fatality.

Patches for carotid artery endarterectomy: current materials and prospects

Patch angioplasty is commonly performed after carotid endarterectomy. Randomized prospective trials and meta-analyses have documented improved rates of perioperative and long-term stroke prevention as well as reduced rates of restenosis for patches compared with primary closure of the arteriotomy. Although use of vein patches is considered to be the gold standard for patch closure, newer generations of synthetic and biologic materials rival outcomes associated with vein patches. Future bioengineered patches are likely to optimize patch performance, both by achieving minimal stroke risk and long-term rates of restenosis as well as by minimizing the risk of unusual complications of prosthetic patches such as infection and pseudoaneurysm formation. In addition, lessons from bioengineered patches will likely enable construction of bioengineered and tissue-engineered bypass grafts.

Primary closure, routine patching, and eversion endarterectomy: what is the current state of the literature supporting use of these techniques?

Our objective in this article was to review the most recent literature on the status of carotid patching or primary carotid closure following carotid endarterectomy; to determine the best patch material if needed; and to clarify the place of eversion carotid endarterectomy in management of carotid artery atherosclerosis. In order to accomplish this, a literature review was performed of the Ovid, PubMed and MedLine databases using appropriate search terms. An evidence-based approach was taken; with all articles graded using the Scottish Intercollegiate Guidelines Network system (levels of evidence 1 to 5) and recommendations were made using an A to D system. Most weight was given to well-conducted, adequately powered, randomized control trials. After review of the literature, we were able to make the following Grade A recommendation: carotid patching is superior to primary closure, resulting in fewer postoperative strokes and a lower incidence of restenosis in most surgeons' hands. However, it was also concluded that, based on review of the literature, that the choice of patch material in 2007 has little impact; eversion carotid endarterectomy (CEA) and conventional patch CEA have equivalent postoperative morbidity and similar incidences of long-term restenosis. In conclusion, the technique of CEA continues to evolve, but in most reported series, immediate and long-term outcomes are excellent. A variety of technical approaches are acceptable, but it appears that carotid patching remains superior to primary closure.

15 year experience of carotid endarterectomy at the Royal Brisbane and Women's Hospital: outcomes and changing trends in management

OBJECTIVE

The aim of this study was to review the results of carotid endarterectomy (CEA) at the Royal Brisbane and Women's Hospital (RBWH) to provide a benchmark for comparison with carotid stenting and to document changes in imaging and procedural techniques over time.

METHODS

Analysis of RBWH CEA database from 1992 to 2007.

RESULTS

1313 consecutive patients (average age 69.2 years, 9% 80 years or older, 69% males) underwent carotid endarterectomy at the RBWH between 1992 and May 2007. Indication for surgery was symptomatic disease in 67%. Preoperative investigations included a duplex scan in 97%, an angiogram in 24% and a CT brain in 33%. Angiogram related neurological events occurred in 3.5% of patients (1.6% stroke, 1.9% TIA). There were 7 deaths (0.5%) and 28 strokes (2.1%) for a combined stroke and death rate of 2.4%. The rate of transient ischemic attacks was 1.1%. Gender patch use and trainees operating with the surgeon unscrubbed predicted a higher combined stroke and death rate. Trends over time included: reduction in preoperative angiography from 66% to <5% and increased rate of patching from 39% to approximately 100%.

CONCLUSIONS

Performance of CEA at the RBWH is in keeping with published literature standards. There has been an evolution to surgery performed on the basis of duplex ultrasound alone and an almost universal use of patching.

Restenosis after carotid endarterectomy

Multiple randomised trials over the last decade for both symptomatic and asymptomatic carotid stenosis have proven the efficacy of carotid endarterectomy (CE) in reducing the risk of stroke. The long-term patency of the carotid artery after CE is an important factor in the success of the operation. The incidence of recurrent carotid stenosis (excluding residual lesions) ranges from 1 to 37% with only 0-8% of patients having restenosis-related symptoms (1). Generally, recurrent carotid stenosis is attributed to myointimal hyperplasia during the early postoperative period (within 3 years) or recurrent atherosclerosis thereafter. The management of recurrent carotid stenosis after CE remains a dilemma. It is generally accepted that operation for significant recurrent carotid stenosis is indicated for symptomatic patients, and several authors also recommend CE for >80% asymptomatic recurrent stenosis. Treatment of recurrent carotid stenosis involves repeat endarterectomy with patch angioplasty, although more recently endovascular techniques have been used.

Sequential cohort study of Dacron patch closure following carotid endarterectomy

BACKGROUND

Carotid endarterectomy reduces the risk of stroke and death in patients with severe carotid artery stenosis. This study examined whether the technique used to close the arteriotomy influenced the rate of perioperative transient ischaemic attack (TIA), stroke or death.

METHODS

A cohort of 236 patients undergoing carotid endarterectomy at a single centre was studied; 117 patients had primary closure of the arteriotomy and 119 patients in a sequential series had closure with a Dacron patch. A standard endarterectomy with completion intraoperative duplex imaging and digital subtraction angiography was used throughout.

RESULTS

Patch closure was associated with a significant reduction in the 30-day combined death, stroke and TIA rate: 10.3 per cent for primary closure versus 2.5 per cent for patch closure (P = 0.017). The risk of any cerebral event (stroke or TIA) was also significantly reduced (7.7 versus 1.7 per cent; P = 0.033). Residual stenosis on completion angiography was more common after primary closure (24.6 versus 7.4 per cent; P = 0.003).

CONCLUSION

Dacron patch closure had a higher technical success rate on completion imaging and was associated with a significant reduction in the risk of perioperative stroke, TIA and death.

Patch angioplasty versus primary closure for carotid endarterectomy

BACKGROUND

Carotid patch angioplasty (with either a venous or a synthetic patch) may reduce the risk of carotid artery restenosis and subsequent ischaemic stroke.

OBJECTIVES

The objective of this review was to assess the safety and efficacy of routine or selective carotid patch angioplasty compared to carotid endarterectomy with primary closure.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched November 2002). In addition, we searched the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), MEDLINE (1966 to December 2001), EMBASE (1980 to December 2001) and Index to Scientific and Technical Proceedings (1980 to 2001). We also handsearched eight journals and five conference proceedings. Reference lists were checked and we contacted experts in the field to identify further published and unpublished studies.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing carotid patch angioplasty with primary closure in any patients undergoing carotid endarterectomy.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed eligibility, trial quality and extracted the data.

MAIN RESULTS

The previous review included six trials involving 794 patients undergoing 882 operations. Since the last review only one study of adequate quality to be included has been reported. This added 399 operations randomised to either primary closure, vein patch or synthetic patch groups resulting in 1127 patients undergoing 1307 operations being available for analysis. The quality of trials was generally poor. Follow-up varied from hospital discharge to five years. Carotid patch angioplasty was associated with a reduction in the risk of stroke of any type (OR = 0.33, p = 0.004), ipsilateral stroke (OR = 0.31, p = 0.0008), and stroke or death, during the perioperative period (OR = 0.39, p = 0.007) and long term follow-up (OR = 0.59, p = 0.004). It was also associated with a reduced risk of perioperative arterial occlusion (odds ratio 0.15, 95% confidence interval 0.06 to 0.37 p = 0.00004), and decreased restenosis during long-term follow-up in five trials, (odds ratio 0.20, 95% confidence interval 0.13 to 0.29 p < 0.00001). These results are more certain than those of the previous review since the number of operations and events have increased. However, the sample sizes are still relatively small, data were not available from all trials, and there was significant loss to follow-up. Very few arterial complications, including haemorrhage, infection, cranial nerve palsies and pseudo-aneurysm formation were recorded with either patch or primary closure. No significant correlation was found between use of patch angioplasty and the risk of either perioperative or long-term all-cause death rates

REVIEWERS' CONCLUSIONS

Limited evidence suggests that carotid patch angioplasty may reduce the risk of perioperative arterial occlusion and restenosis. It would appear to reduce the risk of combined death or stroke and there is a non significant trend towards a reduction in all-cause mortality.