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

Outcome of primary closure following carotid endarterectomy with a novel technique: An 8-year multicenter cohort study

This study evaluated the safety and efficacy of a novel primary closure technique in carotid endarterectomy compared with traditional methods. Conducted over 8 years at three university hospitals, this study included 184 patients. Early complications (8.7%) included hematoma, transient ischemic attack, myocardial infarction, stroke, and death. Late complications involved myocardial infarction, death, transient ischemic attack, stroke, and reintervention. The 1-year follow-up showed a significant (>70%) restenosis rate of only 1.9%. The novel technique in carotid endarterectomy seems to be a safe and effective alternative to patch angioplasty, offering advantages for selected patients. Further studies are required.

Posterior cervical triangle approach for carotid endarterectomy: Technical note and results

INTRODUCTION

Carotid endarterectomy (CEA) is usually performed using the anterior cervical triangle as a surgical corridor but, when needed, the retromandibular space makes dissection of higher structures difficult in some cases. The posterior cervical triangle (PCT) can be useful in these demanding cases.

METHODS

We retrospectively reviewed cases from July 2013 to November 2019 in which PCT was used as an approach for CEA. The surgical technique used was explained, and the complications and evolution of the patients were analysed.

RESULTS

We found 7 CEAs performed through this approach, of which 2 presented transient trapezius paresis. There were no cases of severe complications in this series.

CONCLUSION

The PCT approach for performing CEA represents a useful and easy technique that avoids the need for mandibular mobilisation or osteotomies for lesions located in anatomically high carotid bifurcations.

Primary arterial closure after carotid endarterectomy is a safe and expeditious technique in appropriately selected patients

BACKGROUND

Carotid endarterectomy (CEA) remains a safe and durable operation for both symptomatic and asymptomatic carotid stenosis, however conflicting evidence exists on the benefit of patch angioplasty and its effects on post-operative outcomes.

METHODS

A retrospective review of all patients undergoing CEA from 2011 to 2018 was performed.

RESULTS

Of 851 patients, primary closure was performed in 277 (33%). Patients with primary closure were older (74 vs 72, p = 0.001), symptomatic (39% vs 34%, p = 0.024), and male (69% vs 31% p < 0.001), with a higher incidence of diabetes mellitus (47% vs 39%, p = 0.046) and ESRD (4% vs 2%, p = 0.015). Restenosis rates were similar (7% vs 8%, p = 0.67). Operative time was shorter for primary closure (87 ± 28 vs 102 ± 26 min, p < 0.001). There were no differences in 30-day ipsilateral stroke rates (1% vs 1%, p = 0.51) or stroke-free survival.

CONCLUSIONS

Primary arterial closure is safe and expeditious in appropriately selected high-risk patients.

Selection criteria for patch angioplasty material in carotid endarterectomy

Background:

Carotid endarterectomy (CEA) with patch angioplasty has been favored due to its lower reoccurrence of restenosis compared to primary CEA. There are multiple types of patch angioplasty material available. However, selection of patch material is based on uncertain criteria. The aim of this study is to determine the ideal criteria for selecting the best patch material for CEA.

Methods:

We conducted a comprehensive literature search for studies that describe the ideal criteria for selecting patch material for CEA. We compiled all of the criteria mentioned into one table and selecting the criteria which were most frequently mentioned with a simple scoring system.

Results:

A total of 65 studies out of 784 studies were assessed for its full-text eligibility. Thus, we found 23 studies that were eligible for analysis. There are 22 ideal criteria that were mentioned in the analyzed studies. We grouped these criteria into physical characteristics, safety, contribution to hemodynamic, contribution in tissue healing, economic aspect, and ability to prevent postsurgical complication. We proposed 10 ideal criteria for guiding vascular surgeon in selecting the best patch angioplasty material.

Conclusion:

To this day, no material has been discovered which meets all ten criteria. This study’s proposed ideal criteria serve as the foundation for the creation of the best patch angioplasty material.

Guideline on carotid surgery for stroke prevention: updates from the Italian Society of Vascular and Endovascular Surgery. A trend towards personalized medicine

BACKGROUND

This guideline (GL) on carotid surgery as updating of "Stroke: Italian guidelines for Prevention and Treatment" of the ISO-SPREAD Italian Stroke Organization-Group, has recently been published in the National Guideline System and shared with the Italian Society of Vascular and Endovascular Surgery (SICVE) and other Scientific Societies and Patient's Association.

METHODS

GRADE-SIGN version, AGREE quality of reporting checklist. Clinical questions formulated according to the PICO model. Recommendations developed based on clinical questions by a multidisciplinary experts' panel and patients' representatives. Systematic reviews performed for each PICO question. Considered judgements filled by assessing the evidence level, direction, and strength of the recommendations.

RESULTS

The panel provided indications and recommendations for appropriate, comprehensive, and individualized management of patients with carotid stenosis. Diagnostic and therapeutic processes of the best medical therapy, carotid endarterectomy (CEA), carotid stenting (CAS) according to the evidences and the judged opinions were included. Symptomatic carotid stenosis in elective and emergency, asymptomatic carotid stenosis, association with ischemic heart disease, preoperative diagnostics, types of anesthesia, monitoring in case of CEA, CEA techniques, comparison between CEA and CAS, post-surgical carotid restenosis, and medical therapy are the main topics, even with analysis of uncertainty areas for risk-benefit assessments in the individual patient (personalized medicine [PM]).

CONCLUSIONS

This GL updates on the main recommendations for the most appropriate diagnostic and medical-surgical management of patients with atherosclerotic carotid artery stenosis to prevent ischemic stroke. This GL also provides useful elements for the application of PM in good clinical practice.

Carotid endarterectomy with patch angioplasty versus primary closure in patients with symptomatic and significant stenosis: a systematic review with meta-analyses and trial sequential analysis of randomized clinical trials

BACKGROUND

Patch angioplasty in conventional carotid endarterectomy is suggested to reduce the risk of restenosis and recurrent ipsilateral stroke compared with primary closure. A systematic review of randomized clinical trials is needed to compare outcomes (benefits and harms) of both techniques.

METHODS

Searches (CENTRAL, PubMed/MEDLINE, EMBASE, and other databases) were last updated 3rd of January 2021. We included randomized clinical trials comparing carotid endarterectomy with patch angioplasty versus primary closure of the arterial wall in patients with a symptomatic and significant (> 50%) carotid stenosis. Primary outcomes are defined as all-cause mortality and serious adverse events.

RESULTS

We included 12 randomized clinical trials including 2187 participants who underwent 2335 operations for carotid stenosis comparing carotid endarterectomy with patch closure (1280 operations) versus carotid endarterectomy with primary closure (1055 operations). Meta-analysis comparing carotid endarterectomy with patch angioplasty versus carotid endarterectomy with primary closure may potentially decrease the number of patients with all-cause mortality (RR 0.53; 95% CI 0.26 to 1.08; p = 0.08, best-case scenario for patch), serious adverse events (RR 0.73; 95% CI 0.56 to 0.96; p = 0.02, best-case scenario for patch), and the number of restenosis (RR 0.41; 95% CI 0.23 to 0.71; p < 0.01). Trial sequential analysis demonstrated that the required information sizes were far from being reached for these patient-important outcomes. All the patient-relevant outcomes were at low certainty of evidence according to The Grading of Recommendations Assessment, Development, and Evaluation.

CONCLUSIONS

This systematic review showed no conclusive evidence of a difference between carotid endarterectomy with patch angioplasty versus primary closure of the arterial wall on all-cause mortality, < 30 days mortality, < 30 days stroke, or any other serious adverse events. These conclusions are based on data from 15 to 35 years ago, obtained in trials with very low certainty according to GRADE, and should be interpreted cautiously. Therefore, we suggest conducting new randomized clinical trials patch angioplasty versus primary closure in carotid endarterectomy in symptomatic patients with an internal carotid artery stenosis of 50% or more. Such trials ought to be designed according to the Standard Protocol Items: Recommendations for Interventional Trials statement (Chan et al., Ann Intern Med 1:200-7, 2013) and reported according to the Consolidated Standards of Reporting Trials statement (Schulz et al., 7, 2010). Until conclusive evidence is obtained, the standard of care according to guidelines should not be abandoned.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014013416 . Review protocol publication 2019 DOI: https://doi.org/10.1136/bmjopen-2018-026419 .

[Personalized brain revascularization: computer modeling of the reconstruction zone for carotid endarterectomy]

OBJECTIVE

To develop a technique of computer modeling of hemodynamics before conventional CEE.

MATERIAL AND METHODS

Classical CEE is performed according to conventional patch technique. Duplex parameters of stenosis and blood flow velocity in the carotid arteries were analyzed by using of a linear transducer 7-7.5 MG (Acuson 128XP scanner, Acuson, USA). Multispiral computed tomography with angiography and subsequent processing of data using the Clear canvas software were performed to visualize the main geometric characteristics of the carotid arteries and features of atherosclerotic plaque.

RESULTS

Blood flow hemodynamics is essential in the occurrence of postoperative restenosis. Therefore, computer simulation of blood flow using CFD (Computational Fluid Dynamics) methods based on particular patient's data makes it possible to assess localization of zones with high risk of restenosis. CFD approach implies construction of blood flow parameters at absolutely every point of the vessel considering geometric shape of the vessel and flow characteristics at the entrance and exit from the vessel. Pressure curves at the inlet and outlet are constructed using blood flow velocity curves. Pressure curves are subsequently used in the CFD model. The result of blood flow CFD modeling is non-stationary three-dimensional fields of pressure and velocity in the investigated area. Visual analysis of blood flow dynamics in these fields makes it possible to judge possible problem areas along the blood flow and on the inner wall of the vessel.

DISCUSSION

Patch technique of classical CEE is characterized by great risk of parietal thrombosis and hyperproliferation of neointima that explains more frequent development of restenosis. Computer modeling is valuable to consider some important technical aspects in implementation of various surgical techniques for carotid artery reconstruction.

CONCLUSION

This result demonstrates an importance of achieving the optimal ratio of the diameter of common, internal and external carotid arteries. Modification of patch based on computer simulation is required for these purposes.