Literature review of primary versus patching versus eversion as carotid endarterectomy closure

Comparative on the effectiveness and safety of different carotid endarterectomy techniques: a single-center Retrospective Study

BACKGROUND

Carotid endarterectomy (CEA) is a surgical procedure that can reduce the risk of stroke in patients with carotid artery stenosis. However, controversy still exists regarding the optimal surgical technique for CEA.

OBJECTIVE

To compare the safety and effectiveness of different techniques.

METHODS

Data on baseline characteristics as well as perioperative and postoperative complications from patients who underwent CEA at the Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, were retrospectively collected and analyzed.

RESULTS

A total of 262 CEA patients included in study, with a total of 265 CEA operations. The mean age of 69.95 ± 7.29 (range, 44-89) years. 65 (24.5%) patients underwent cCEA, 94 (35.5%) underwent pCEA, and 106 (40.0%) underwent eCEA. The use of shunt (1.9%) and the mean operation time were lower in eCEA group (P < 0.05). eCEA was also associated with a lower incidence of postoperative hypotension, whereas pCEA was associated with a lower incidence of postoperative hypertension (P < 0.05). There was no significant difference in clinical baseline characteristics, occurrence of perioperative complications, and survival whether restenosis-free, asymptomatic or overall.

CONCLUSIONS

This study found that all three surgical methods are equally safe for the treatment of carotid artery stenosis and are effective in preventing stroke.

Contemporary open surgical approaches for the management of carotid stenosis: a comprehensive review

This study aims to provide an overview on contemporary open surgical approaches for the management of carotid artery stenosis. A comprehensive literature search was performed to identify and categorize open surgery intervention techniques for the management of carotid artery stenosis, focusing on the benefits and drawbacks of each technique. Five surgical techniques for carotid endarterectomy (CEA) have been described: CEA with primary closure, CEA with patch closure, CEA by eversion technique, CEA by modified eversion technique and CEA by partial eversion. Evidence has reported significantly higher rates of perioperative complications after CEA with primary closure, including 30-days stroke rate and late restenosis. Although more recent techniques have been reported to provide superior outcomes, electing the best surgical technique is still a matter of debate. Also, CEA using a mini-skin incision has been associated to lower risk of cranial/cervical nerve injury and shorter length of hospital stay. The selection of the surgical intervention should be tailored and have into consideration individual patient characteristics, clinical considerations, surgeon preference and surgical team expertise. Further large-scale randomized clinical trials are needed to support more robust decisions on the choice of contemporary open surgical approaches to manage carotid stenosis.

Temporal Trends and Contemporary Regional Variation in Management of Patients Undergoing Carotid Endarterectomy

INTRODUCTION

The purpose of this study is to investigate regional variation and temporal trends in seven quality metrics amongst CEA patients: discharge on antiplatelet after CEA; discharge on statin after CEA; protamine administration during CEA; patch placement at conventional CEA site; continued statin usage at the time of most recent follow-up; continued antiplatelet usage at the time of most recent follow-up; and smoking cessation at the time of long term follow up.

METHODS

There are 19 de-identified regions within the VQI database in the United States. Patients were placed into one of three temporal eras based on the time of their CEA: 2003-2008; 2009-2015; and 2016-2022. We first investigated temporal trends across the seven quality metrics for all regions combined on a national basis. The percentage of patients in each time era with the presence/absence of each metric was identified. Chi-squared testing was performed to confirm statistical significance of the differences across eras. Next, analysis was performed within each region and within each time metric. We separated out the 2016-2022 patients within each region to serve as the status of each metric application in the most modern era. We then compared the frequency of metric non-adherence in each region utilizing Chi-squared testing.

RESULTS

There was statistically significant improvement in achievement of all seven metrics between the initial 2003-2008 era and the modern 2016-2022 era. The most marked change in practice pattern was noted for lack of protamine usage at surgery (decreased from 48.7% to 25.9%), discharge home postoperatively without statin (decreased from 50.6% to 15.3%), and lack of statin usage confirmed at time of most recent long term follow up (decreased from 24% to 8.9%). Significant regional variation exists across all metrics (P < .01 for all). Lack of patch placement at the time of conventional endarterectomy ranges from 1.9% to 17.8% across regions in the modern era. Lack of protamine utilization ranges from 10.8% to 49.7%. Lack of antiplatelet and statin at the time of discharge varies from 5.5% to 8.2% and 4.8% to 14.4% respectively. Adherence to the various measures at the time of most recent follow up are more tightly aligned across regions with ranges of: 5.3% to 7.5% for lack of antiplatelet usage; 6.6% to 11.7% lack of statin utilization; and 13.3 to 15.4% for persistent smoking.

CONCLUSIONS

Prior studies and societal initiatives on CEA documenting the beneficial effects of patch angioplasty, protamine use at surgery, smoking cessation, antiplatelet utilization and statin compliance have positively impacted adherence to these measures over time. In the modern 2016-2022 era the widest regional variation is noted in patch placement, protamine utilization and discharge medications allowing individual geographic areas to identify areas for potential improvement via internal VQI administrative feedback.

Regional variation in patient selection, practice patterns, and outcomes based on techniques for carotid artery revascularization in the Vascular Quality Initiative

OBJECTIVE

Significant regional variation is known with multiple surgical procedures. This study describes regional variation in carotid revascularization within the Vascular Quality Initiative (VQI).

METHODS

Data from the VQI carotid endarterectomy (CEA) and carotid artery stenting (CAS) databases from 2016 to 2021 were used. Nineteen geographic VQI regions were divided into three tertiles based on the average annual volume of carotid procedures performed per region (low-volume: 956 cases [range, 144-1382]; medium-volume: 1533 cases [range, 1432-1589]; and high-volume: 1845 cases [range, 1642-2059]). Patients' characteristics, indications for carotid revascularization, practice patterns, and outcomes (perioperative and 1-year stroke/death) of different revascularization techniques were compared between these regional groups. Regression models that adjust for known risk factors and allow for random effects at the center level were used.

RESULTS

CEA was the most common revascularization procedure (>60%) across all regional groups. Significant regional variation was observed in the practice of CEA such as variability in the use of shunting, drain placement, stump pressure and electroencephalogram monitoring, intraoperative protamine, and patch angioplasty. For transfemoral CAS, high-volume regions had a higher proportion of asymptomatic patients with <80% stenosis (30.5% vs 27.8%) in addition to higher use of local/regional anesthesia (80.4% vs 76.2%), protamine (16.1% vs 11.8%), and completion angiography (81.6% vs 77.6%) during transfemoral carotid artery stenting (TF-CAS) compared with low-volume regions. For transcarotid artery revascularization (TCAR), high-volume regions were less likely to intervene on asymptomatic patients with <80% stenosis (32.2% vs 35.8%) than low-volume regions. They also had a higher proportion of urgent/emergent procedures (13.6% vs 10.4%) and were more likely to use general anesthesia (92.0% vs 82.1%), completion angiography (67.3% vs 63.0%), and poststent ballooning (48.4% vs 36.8%). For each carotid revascularization technique, no significant differences were noted in perioperative and 1-year outcomes between low-, medium-, and high-volume regions. Finally, there were no significant differences in outcomes between TCAR and CEA across the different regional groups. In all regional groups, TCAR was associated with a 40% reduction in perioperative and 1-year stroke/death compared with TF-CAS.

CONCLUSIONS

Despite significant variation in clinical practices for the management of carotid disease, no regional variation exists in the overall outcomes of carotid interventions. TCAR and CEA continue to show superior outcomes to TF-CAS across all VQI regional groups.

History of Carotid Artery Reconstruction around the World and in Japan

Since ancient times, physicians have been aware of correlations between the carotid artery and consciousness; however, carotid stenosis was only recently identified as the cause of atherothrombotic ischemic stroke. In 1658, Wepfer described the first suggestion of a link between symptoms of cerebral arterial insufficiency and carotid pathology. In 1951, Fisher reported details of the symptoms and pathological findings and emphasized that cervical atheromatous lesions induced cerebral infarction with various symptoms. The beginning of carotid artery surgery was ligation of the carotid artery for neck or head injury, but surgeons were aware that this operation induced cerebral symptoms due to lack of blood supply. Carotid endarterectomy (CEA) was first reported by Eastcott et al. in 1954, and in Japan, Kimoto performed a successful CEA in 1962. In 1979, percutaneous transluminal angioplasty (PTA) was performed for patients with fibromuscular dysplasia, and then, carotid artery stenting (CAS) was first performed in 1989 by Mathias. In Japan, Kuwana et al. were the first to perform carotid PTA, in 1981, whereas Yamashita et al. performed the first CAS in 1997. Yoshimura et al. proposed staged carotid stenting to prevent hyperperfusion syndrome. Some issues in carotid reconstruction are still debated today, which include conventional (standard) CEA versus the eversion technique, CEA versus CAS versus medical therapy, and medical economic problems. In the future, we must continue to develop more effective, safer, and less expensive therapeutic methods to prevent carotid stroke, carrying on the efforts of the ancient peoples who pioneered this research.

Comparison of Clinical Outcomes in Patients Undergoing Common Femoral Thromboendarterectomy With or Without Patch Angioplasty

OBJECTIVE

Surgical thromboendarterectomy (TEA) is the standard treatment for an occlusive lesion of the common femoral artery (CFA). However, there is limited knowledge on the need for patch angioplasty in CFA TEA. The objective of this study was to compare the peri-operative and two year results of CFA TEA with or without patch angioplasty.

METHODS

A multicentre retrospective observational study was performed at 34 Japanese centres. Comparisons were made between patients undergoing CFA TEA with or without patch angioplasty after propensity score matching (PSM). The primary endpoints were primary patency and freedom from target lesion revascularisation (TLR) of the TEA lesion. The secondary endpoints were hospital outcomes, limb salvage, and overall survival.

RESULTS

Between 2018 and 2020, 428 TEA procedures (237 with patch angioplasty and 191 with primary closure) were performed. PSM extracted 151 pairs with no significant intergroup differences in baseline characteristics. Peri-operative death and complications occurred in 0.7% vs. 1.3% (p = 1.0) and 6.0% vs. 6.6% (p = 1.0), respectively. The follow up rate was 96% over a median follow up of 14.9 months (interquartile range 8.3, 24.3). Loss of primary patency occurred in 18 patients. The two year primary patency of patch angioplasty cases was statistically significantly higher than that of primary closure cases (97.0% vs. 89.9%; p = .021). TLR was performed in 14 patients. The two year freedom from TLR in patch angioplasty cases was also statistically significantly higher than in primary closure cases (98.6% vs. 92.9%; p = .003). During follow up, seven limbs required major amputation and 40 patients died. There was no statistically significant difference in limb salvage and survival between the two groups after PSM.

CONCLUSIONS

This is the first report to show that patch angioplasty may decrease re-stenosis and target lesion revascularisation of CFA TEA lesions.

Long-term durability and clinical outcome of a prospective randomized trial comparing carotid endarterectomy with ACUSEAL polytetrafluoroethylene patching versus pericardial patching

BACKGROUND

Several studies have shown the superiority of carotid endarterectomy (CEA) with patch closure over primary closure. However, no definite study has shown any significant differences in clinical outcome between various types of patches. Because more vascular surgeons have used pericardial patching recently, this study will analyze the late clinical outcome (≥10 years) of our previously reported prospective randomized trial comparing CEA with ACUSEAL (polytetrafluoroethylene) vs pericardial patching.

METHODS

A total of 200 CEAs were randomized (1:1) to either Vascu-Guard pericardial patching or ACUSEAL patching. All patients had immediate duplex ultrasound imaging, which was repeated at 6 months and annually thereafter. Kaplan-Meier analysis was used to estimate rates of freedom from stroke, stroke-free survival, and rates of freedom from ≥50% and ≥80% restenosis.

RESULTS

Overall demographic and clinical characteristics were somewhat similar with a mean follow-up of 80 months (range: 0-149 months). The rates of freedom from stroke were 97, 97, 97, 96, 93 for ACUSEAL vs 99, 98, 97, 97, 92 for pericardial patching (P = .1112) at 1, 2, 3, 5, and 10 years, respectively. Similarly, the rates of freedom from stroke/death were 94, 93, 90, 76, 50 for ACUSEAL vs 99, 96, 91, 78, 47 for pericardial patching (P = .8591). The rates of freedom from ≥50% restenosis were 98, 98, 96, 89, 79 for ACUSEAL vs 87, 83, 83, 81, 71 for pericardial patching (P = .0489). The rates of freedom from ≥80% restenosis were 99, 99, 99, 96, 85 for ACUSEAL vs 96, 96, 96, 93, 93 for pericardial patching (P = .9407). The overall survival rates were 95, 94, 91, 77, 51 for ACUSEAL vs 100, 98, 93, 79, 50 for pericardial patching (P = .9123). Other patch complications (eg, rupture, aneurysmal dilation, infection, etc) were similar.

CONCLUSIONS

Both CEA with ACUSEAL (polytetrafluoroethylene) and pericardial patching are durable and have similar clinical outcomes at 10 years except that ACUSEAL patching has significantly better rates of freedom from ≥50% restenosis.

Biodegraded PCl and gelatin fabricated vascular patch in rat aortic and inferior vena cava angioplasty

Novel synthetic prosthesis materials for patch angioplasty are continuously under development and optimization. When a nonwoven-based gelatin membrane is coupled with an electrospun layer of polycaprolactone (PCL), these biohybrid polymer membranes (BHMs) possess higher mechanical properties in aqueous environments. We hypothesized that BHMs can also be used as vascular patches, and we tested our hypothesis in a rat IVC venoplasty and aortic arterioplasty model. Patch venoplasty and arterioplasty were performed in SD rats (200 g), the patches were harvested at day 14, and samples were analyzed by immunohistochemistry and immunofluorescence. The BHM patches were almost degraded, with few parts remaining after 14 days. There was a line of CD34- and nestin-positive cells on the endothelium, with some cells were CD34 and nestin dual-positive, macrophages and leukocytes also participated in the patch healing process. There were PCNA-positive cells in the neointima and peri-patch area, with some cells were also PCNA and α-actin dual-positive. Arterial neointimal endothelial cells were Ephrin-B2- and dll-4-positive, and venous neointimal endothelial cells were Eph-B4- and COUP-TFII-positive. BHM shares a similar healing process like other patch materials, and BHM may have potential applications in vascular surgery.