Primary Closure, Routine Patching, and Eversion Endarterectomy: What is the Current State of the Literature Supporting Use of These Techniques?

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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.

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Methods

A search was made of PubMed, MedLine, and the Ovid databases using the following search terms: carotid endarterectomy, patch, eversion, primary closure, long term results, and angioplasty for published articles, clinical evidence articles, and meta-analyses. For this review, we used the British Medical Journal system, first described in 20014 (more properly the Scottish Intercollegiate Guidelines Network) to evaluate articles and make recommendations (Table 1). There are numerous methods for

Question 1: Is Carotid Patch Angioplasty Better Than Primary Closure?

Carotid vein patching was used routinely by Imparato14 as early as 1965 and the first comparison between primary carotid artery closure and patch angioplasty in animals was published in 1964.15 There have been eight RCTs published since 1987, directly comparing patch angioplasty with traditional primary closure.16, 17, 18, 19, 20, 21, 22, 23 There have been two meta-analyses of the RCTs by the Cochrane Collaborative database (level 1++ evidence) in 2000 and 200424, 25 and another meta-analysis

Question 2: Is Selective Patching of the Carotid Artery During CEA an Acceptable Approach?

Selective patching is seen as a way of reducing operating time in selected patients with larger ICAs (usually >4 mm) who have short plaques. It is obviously practiced to good effect by a large number of surgeons. It is also clear that when ICAs are tortuous or exceptionally narrow, they are patched as a matter of course. Naturally, it is difficult to assess a selective approach in RCTs, given its subjective nature.

Question 3: Is There Any Difference in Outcomes Based on Use of Vein or Prosthetic Patching During CEA?

With the assumption that patching is better than primary closure, the question then is whether it is better to patch with autologous material, such as saphenous vein or everted external jugular vein, or to use prosthetic material. Given the expected margin of difference between the two techniques, the number of patients required to adequately power such a study would be large (Table 3, Table 4).

Question 4: Is a Dacron Patch Better Than ePTFE?

Use of a synthetic patch has obvious attractions: opening a packet to obtain a patch is quicker than harvesting groin or ankle vein and is usually associated with fewer complications. Initially, patching was performed mostly with ePTFE. However, concerns about prolonged bleeding times led to the introduction of collagen-impregnated Dacron patches. A new modified ePTFE has been introduced, which is claimed to have better hemostatic properties. That one patch material is superior to another is a

Question 5: Is Conventional CEA Better than Eversion CEA?

Eversion CEA, as currently practiced, was first performed by Kieny in 1985,55, 56 improving upon the technique described by DeBakey57 from 1959 and Etheredge58 in 1970. The DeBakey/Etheredge technique involved transecting the common carotid artery and everting internal and external carotid artery as one; the Kieny technique confines eversion to the ICA only. The purported benefits of eCEA are a lower restenosis rate and lower stroke rate compared to either primary closure or patch angioplasty

Discussion

After 54 years, most questions regarding carotid surgery ought to have been answered by well-conducted RCTs. There have been some notable successes. Good-quality studies have relegated extracranial to intracranial bypass to an historical footnote73 and have shown that CEA is better than medical therapy for symptomatic or asymptomatic carotid disease.74, 75, 76 So why do the arguments rumble on despite numerous RCTs? The issue, as Archie77 and Counsell et al78 pointed out, is one of power. Power

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