Subscribe to RSS
Patch Angioplasty or Primary Closure Following Carotid Endarterectomy for Symptomatic Carotid Artery Stenosis
04 March 2018
17 April 2018
15 June 2018 (online)
Objectives Guidelines recommend routine patching to prevent restenosis following carotid endarterectomy, mainly based on studies performed many years ago with different perioperative care and medical treatment compared with current standards. Aim of the present study was to compare primary closure (PRC) versus patch closure (PAC) in a contemporary cohort of patients.
Methods Consecutive patients treated by carotid endarterectomy for symptomatic stenosis between January 2006 and April 2016 were retrospectively analyzed. Primary outcome was restenosis at 6 weeks and 1 year and occurrence of ipsilateral stroke. Secondary outcomes were mortality, complications, and reintervention rates.
Results Five hundred carotid artery endarterectomies were performed. Fifty-nine patients were excluded because eversion endarterectomy was performed or because they were asymptomatic. PRC was performed in 349 and PAC in 92 patients. Restenosis at 6 weeks was 6.0% in the PAC group versus 3.0% in the PRC group (p = 0.200). Restenosis at 1 year was 31.6 versus 14.1%, respectively (p = 0.104). No difference was found for stroke (3.4 vs 1.1%, p = 0.319), death (1.1 vs 0.0%, p = 0.584), or other complications (1.1 vs 0.0%, p = 0.584), respectively.
Conclusions It remains unclear whether routine patching should be recommended for all patients. A strategy of selective patching compared with routine patching, based on internal carotid artery diameter and other patient characteristics, deserves further investigation.
Keywordscarotid endarterectomy - patching - patch angioplasty - primary closure - restenosis - ipsilateral stroke
Ethics Approval and Consent
This study was approved by the Noordwest Clinics Alkmaar Ethics Committee and the requirement for informed consent was waived by the committee.
EH data collection, data analysis, writing draft of manuscript.
CV conception and design, data analysis, interpretation, revising manuscript.
RH data interpretation, revising manuscript.
PA data interpretation, revising manuscript.
GB data interpretation, revising manuscript.
CU conception and design, data analysis, interpretation, revising manuscript.
All authors read and approved the final manuscript.
- 1 Ricotta JJ, Aburahma A, Ascher E, Eskandari M, Faries P, Lal BK. ; Society for Vascular Surgery. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg 2011; 54 (03) e1-e31
- 2 Liapis CD, Bell PR, Mikhailidis D. , et al; ESVS Guidelines Collaborators. ESVS guidelines. Invasive treatment for carotid stenosis: indications, techniques. Eur J Vasc Endovasc Surg 2009; 37 (4, Suppl): 1-19
- 3 Naylor AR, Sayers RD, McCarthy MJ. , et al. Closing the loop: a 21-year audit of strategies for preventing stroke and death following carotid endarterectomy. Eur J Vasc Endovasc Surg 2013; 46 (02) 161-170
- 4 Bekelis K, Moses Z, Missios S, Desai A, Labropoulos N. Indications for treatment of recurrent carotid stenosis. Br J Surg 2013; 100 (04) 440-447
- 5 Arquizan C, Trinquart L, Touboul PJ. , et al; EVA-3S Investigators. Restenosis is more frequent after carotid stenting than after endarterectomy: the EVA-3S study. Stroke 2011; 42 (04) 1015-1020
- 6 Lattimer CR, Burnand KG. Recurrent carotid stenosis after carotid endarterectomy. Br J Surg 1997; 84 (09) 1206-1219
- 7 Rerkasem K, Rothwell PM. Patch angioplasty versus primary closure for carotid endarterectomy. Cochrane Database Syst Rev 2009; (04) CD000160
- 8 Naylor AR, Ricco JB, de Borst GJ. , et al; Writing Group; Esvs Guidelines Committee; Esvs Guideline Reviewers. Editor's choice - management of atherosclerotic carotid and vertebral artery disease: 2017 clinical practice guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 55 (01) 3-81
- 9 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
- 10 Barnett HJ, Taylor DW, Eliasziw M. , et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1998; 339 (20) 1415-1425
- 11 Ouriel K, Rutherford RB. Carotid endarterectomy. In: Atlas of Vascular Surgery: Operative Procedures, 1st ed. Philadelphia, PA: WB Saunders; 1998
- 12 Rerkasem K, Rothwell PM. Systematic review of randomized controlled trials of patch angioplasty versus primary closure and different types of patch materials during carotid endarterectomy. Asian J Surg 2011; 34 (01) 32-40
- 13 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 (03) 757-761
- 14 Bennett KM, Scarborough JE, Shortell CK. Predictors of 30-day postoperative stroke or death after carotid endarterectomy using the 2012 carotid endarterectomy-targeted American College of Surgeons National Surgical Quality Improvement Program database. J Vasc Surg 2015; 61 (01) 103-111
- 15 Avgerinos ED, Chaer RA, Naddaf A, El-Shazly OM, Marone L, Makaroun MS. Primary closure after carotid endarterectomy is not inferior to other closure techniques. J Vasc Surg 2016; 64 (03) 678-683.e1
- 16 Harrison GJ, How TV, Poole RJ. , et al. Closure technique after carotid endarterectomy influences local hemodynamics. J Vasc Surg 2014; 60 (02) 418-427