Outcomes of Carotid Endarterectomy with Primary Closure

Abstract

Carotid endarterectomy (CEA) reduces the risk of stroke in patients with internal carotid artery stenosis, although the optimal surgical technique is debated. The literature suggests that patch angioplasty reduces complication risk, although primary closure shortens cross-clamp time and eliminates complications associated with grafts.

The objective of this study was to assess the complication rate after CEA with primary closure.

Retrospective review of 240 consecutive patients between 2002 and 2010. Of these patients, 70% returned for follow-up visits for at least 2 or more years.

Primary closure was used in all patients. The average cross-clamp time was 18 minutes. Complications in the immediate postoperative period within 30 days were as follows: stroke (n = 3; 1.1%), transient ischemic attack (TIA; n = 4; 1.5%), myocardial infarction (MI; n = 3; 1.1%), and death (n = 1; 0.4%). Short-term follow-up revealed eight patients who were found to have significant restenosis (>80%) by carotid duplex imaging. Two to ten year postoperative complication rates were as follows: stroke (n = 7; 4.2%), TIA (n = 7; 4.2%), amaurosis fugax (n = 1; 0.6%), MI (n = 8; 4.8%), and death (n = 28; 17%). Mortality was due to stroke or heart attack (n = 2; 1.2%), cancer (n = 7; 4.2%), and unknown causes (n = 19; 11%).

This study presents our experience with complications after primary closure after CEA. In our experience, CEA is a safe and effective surgical means of preventing stroke in the short term. Well-designed prospective studies are needed to confirm specific patient characteristics in which primary closure and patch angioplasty are indicated.

Keywords

atherosclerosis - carotid endarterectomy - carotid stenosis - stroke - vessel repair - patch closure - primary closure - carotid endaretectomy outcomes

• References

• 1 Katz D, Snyder SO, Gandhi RH , et al. Long-term follow-up for recurrent stenosis: a prospective randomized study of expanded polytetrafluoroethylene patch angioplasty versus primary closure after carotid endarterectomy. J Vasc Surg 1994; 19 (2) 198-203 , discussion 204–205
• 2 Myers SI, Valentine RJ, Chervu A, Bowers BL, Clagett GP. Saphenous vein patch versus primary closure for carotid endarterectomy: long-term assessment of a randomized prospective study. J Vasc Surg 1994; 19 (1) 15-22
• 3 Malas M, Glebova NO, Hughes SE , et al. Effect of patching on reducing restenosis in the carotid revascularization endarterectomy versus stenting trial. Stroke 2015; 46 (3) 757-761
• 4 Bond R, Rerkasem K, Naylor AR, Aburahma AF, Rothwell PM. Systematic review of randomized controlled trials of patch angioplasty versus primary closure and different types of patch materials during carotid endarterectomy. J Vasc Surg 2004; 40 (6) 1126-1135
• 5 Muto A, Nishibe T, Dardik H, Dardik A. Patches for carotid artery endarterectomy: current materials and prospects. J Vasc Surg 2009; 50 (1) 206-213
• 6 Hertzer NR, Mascha EJ. A personal experience with coronary artery bypass grafting, carotid patching, and other factors influencing the outcome of carotid endarterectomy. J Vasc Surg 2006; 43 (5) 959-968
• 7 Eikelboom BC, Ackerstaff RG, Hoeneveld H , et al. Benefits of carotid patching: a randomized study. J Vasc Surg 1988; 7 (2) 240-247
• 8 Lord RS, Raj TB, Stary DL, Nash PA, Graham AR, Goh KH. Comparison of saphenous vein patch, polytetrafluoroethylene patch, and direct arteriotomy closure after carotid endarterectomy. Part I. Perioperative results. J Vasc Surg 1989; 9 (4) 521-529
• 9 Rerkasem K, Rothwell PM. Patch angioplasty versus primary closure for carotid endarterectomy. Cochrane Database Syst Rev 2009; 4 (4) CD000160
• 10 Saw J. Carotid Artery Stenting: The Basics. Secaucus, NJ: Humana; 2009: 29-32
• 11 El-Sabrout R, Reul G, Cooley DA. Infected postcarotid endarterectomy pseudoaneurysms: retrospective review of a series. Ann Vasc Surg 2000; 14 (3) 239-247
• 12 Maertens V, Maertens H, Kint M, Coucke C, Blomme Y. Complication rate after carotid endarterectomy comparing patch angioplasty and primary closure. Ann Vasc Surg 2016; 30: 248-252
• 13 Archie JP. Carotid endarterectomy saphenous vein patch rupture revisited: selective use on the basis of vein diameter. J Vasc Surg 1996; 24 (3) 346-351 , discussion 351–352
• 14 Van Damme H, Grenade T, Creemers E, Limet R. Blowout of carotid venous patch angioplasty. Ann Vasc Surg 1991; 5 (6) 542-545
• 15 O'Hara PJ, Hertzer NR, Krajewski LP, Beven EG. Saphenous vein patch rupture after carotid endarterectomy. J Vasc Surg 1992; 15 (3) 504-509
• 16 Oldham J, Saha S. Carotid endarterectomy: outcome of “old-fashioned” approach. Int Surg 2011; 96 (1) 60-63
• 17 Clagett GP, Patterson CB, Fisher Jr DF , et al. Vein patch versus primary closure for carotid endarterectomy. A randomized prospective study in a selected group of patients. J Vasc Surg 1989; 9 (2) 213-223
• 18 Hertzer NR, Beven EG, O'Hara PJ, Krajewski LP. A prospective study of vein patch angioplasty during carotid endarterectomy. Three-year results for 801 patients and 917 operations. Ann Surg 1987; 206 (5) 628-635
• 19 Awad IA, Little JR. Patch angioplasty in carotid endarterectomy. Advantages, concerns, and controversies. Stroke 1989; 20 (3) 417-422
• 20 Kapoor R, Evins AI, Marcus J, Rigante L, Kubota M, Stieg PE. Selective patch angioplasty and intraoperative shunting in carotid endarterectomy: a single-center review of 141 procedures. Cureus 2015; 7 (10) e367
• 21 Zenonos G, Lin N, Kim A, Kim JE, Governale L, Friedlander RM. Carotid endarterectomy with primary closure: analysis of outcomes and review of the literature. Neurosurgery 2012; 70 (3) 646-654, discussion 654–655
• 22 Gelabert HA, el-Massry S, Moore WS. Carotid endarterectomy with primary closure does not adversely affect the rate of recurrent stenosis. Arch Surg 1994; 129 (6) 648-654
• 23 Counsell CE, Salinas R, Naylor R, Warlow CP. A systematic review of the randomised trials of carotid patch angioplasty in carotid endarterectomy. Eur J Vasc Endovasc Surg 1997; 13 (4) 345-354