Thirty Year Experience with Selective Patching Following Carotid Endarterectomy (CEA)
Nicholas J. Gargiulo, III, MD FACS RPVI RVT RDMS1, Frank J. Veith, MD FACS2, David O'Connor, MD FACS RPVI RVT3.
1The Brookdale University Hospital and Medical Center, New York, NY, USA, 2NYU and The Cleveland Clinic, New York, NY, USA, 3Hackensack Medical Center at UMDNJ, New York, NY, USA.
OBJECTIVES: Large medicare databases and multiple meta- analyses support the use of patch closure following carotid endarterectomy (CEA). Routine patching reduces perioperative stroke, carotid thrombosis, and restenosis. In addition, the use of a carotid patch during CEA adds significantly to the cost of the procedure. This 30 year experience evaluates the long term outcome of CEA with primary closure versus patch closure of the carotid artery. METHODS: An IRB approved retrospective review of all CEAs performed over a 30 year (1984-2014) period. Preoperative imaging studies, operative reports, physical findings, and co- morbid conditions as well as pre-and postoperative medications were evaluated. Patients having undergone follow-up duplexes are the basis for this review. Restenosis was defined as angiographic criteria suggesting an 80% or more diameter reduction requiring re-intervention. RESULTS:Over a 30-year period, 439 CEAs were performed for symptomatic carotid disease using a selective patch technique depending on gender, internal carotid artery diameter, cardiovascular risk factors, and preoperative arteriogram. In this group of 439 patients, 17 (3.9%) had patch closure of the carotid artery and the other 422 (96.1%) had primary closure. There were 2 (0.47%) perioperative strokes in the primary closure group and 4 (0.95%) patients in this group developed symptomatic carotid restenosis at a mean follow-up of 49.5 months (range 1 to 237 months). There was 1 (5.8%) carotid thrombosis in the patch closure group who also had a perioperative stroke and was serologically positive for a hypercoagulable disorder. The 4 patients who developed symptomatic restenosis had arteriographically proven > 90% stenosis and required repeat CEA. The remaining 418 (99.0%) patients having primary closure remained neurologically asymptomatic (mean follow-up 10.3 years, range 2.5 to 17 years). There was 1 (0.23%) operative death that occurred following the induction of general anesthesia.CONCLUSION: In this experience, there is no statistically significant difference in restenosis in the primary closure and selective patch groups following CEA. These observations do not support the generally well accepted view of routine patching following CEA.
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