Initial experience with primary closure after carotid endarterectomy
Saideep Bose, MD, MPH1, Sagar Rambhia2, Robert Hacker, MD3.
1University Hospitals, Cleveland, OH, USA, 2Case Western Reserve University School of Medicine, Cleveland, OH, USA, 3Mercy St Vincent Medical Center, Toledo, OH, USA.
Objective The current literature suggests that patch angioplasty after carotid endarterectomy reduces the rate of restenosis or subsequent stroke. However, primary closure shortens operative time and eliminates complications associated with prosthetic grafts. Despite the fact that 60-80% of carotid endarterectomies are now closed with a patch, there is increasing evidence that a subset of patients may benefit from primary closure. Recently published favorable case series look at the outcomes of experienced, senior vascular surgeons. There is currently a dearth of data regarding the initial outcomes of a surgeon adopting primary closure as the routine approach for most patients requiring a carotid endarterectomy.
Methods Over a 20-month period, all carotid endarterectomies performed by a single, early-career vascular surgeon at a county hospital were carried out with a primary closure of a longitudinal arteriotomy. All patients were monitored by somatosensory evoked potentials (SSEP) with a selective-shunting strategy. These patients were followed up closely post-operatively with a carotid duplex at 30 days. Patients were monitored for complications including bleeding, infection, evidence of restenosis, stroke, and mortality. It is anticipated that patients will be followed closely for 3 years with a yearly carotid duplex.
Results Over a study period of 20-months, 16 primary carotid endarterectomies were performed in 15 patients primarily for asymptomatic carotid stenosis (75%) and symptomatic carotid stenosis (25%). One patient required placement of a shunt due to SSEP changes upon clamping of the ICA. Average ICA clamp time was 39.2 minutes with an average total operative time of 121 minutes. There were no intra- or post-operative strokes. There were no stenosis >50% seen on follow-up ultrasound at 30 days. 2 patients had new asymptomatic contralateral occlusions. There was one mortality, a patient who died after his second CEA due to a MVC unrelated to his operation.
Conclusions In short-term follow-up, primary closure carotid endarterectomy performed by an early career vascular surgeon has excellent results with similar outcomes to the published data on patch angioplasty.
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