Society For Clinical Vascular Surgery

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Complication rate after carotid endarterectomy comparing patch angioplasty and primary closure: long-term outcome
Vicky L. Maertens, MD, Anneleen Stockman, MD, Cedric Coucke, MD, Yves Blomme, MD, Heidi A. Maertens, MD, PhD, Frank Veith, MD, PhD.
AS Sint Lucas Ghent, Ghent, Belgium.

In patients with severe internal carotid artery stenosis, carotid endarterectomy (CEA) has been shown to reduce risk for stroke. Our previous short term study showed primary closure to be an equivalent closure technique compared to patch angioplasty when used in selected patients. This follow-up study aimed to assess long term complication rate and restenosis after CEA with selective patching.
Two hundred thirteen consecutive CEAs (January 5th 2011 to December 19th 2013) were prospectively analysed in this 5-year follow-up study (mean 4.6 (3.17-6.17). Patient population consisted of 141 males and 72 females with mean age 73 years at the time of surgery (SD 8.57, range 53-95). There was a follow-up of 89%. Risk factors were assessed: hypertension, diabetes mellitus, coronary artery disease and smoking. Symptoms of cranial nerve injury, transient ischemic events, cerebrovascular events and mortality were evaluated. Duplex ultrasound was performed by a radiologist blinded to the operative technique to evaluate patency of the carotid artery after CEA.
Primary closure was used in 110 operations, and patch angioplasty in 103 procedures (Dacron patch). Primary closure was performed when the internal carotid artery had a diameter above 5 mm, when there was a high carotid bifurcation and when the contralateral internal carotid artery was occluded. There were no significant differences among groups' baseline characteristics at the time of surgery. Primary closure was performed significantly more in male patients. (P=0.013). After 5-year follow-up, the patch angioplasty group included significantly more smokers (P=0.004). Overall complication rate after 5 year was 5.84% (2.70% primary, 9.52% patch, P=0.09). Four patients experienced cranial nerve damage, 2 in each group. Five patients had an ipsilateral cerebrovascular thrombosis, all after patch angioplasty (P=0.05). There was no significant difference in restenosis or mortality comparing both groups (Table). There was a correlation between postoperative use of antihypertensive medication and long term stroke (P=0.006), restenosis (P=0.01) and mortality (P=0.003). Conclusions
After long term follow-up we found no higher complication rate or restenosis risk after primary closure compared to patch angioplasty when used in selected patients. Best medical treatment and especially the use of antihypertensive medication should be emphasized.

Primary closure (N = 110)Patch angioplasty (N = 103)P value
Restenosis57 (51.82%)44 (42.72%)P=0.43
Restenosis <50%5138
Restenosis 50-70%66
Restenosis > 70%00
Mortality 26 (23.6%)25 (24.3%)P=0.40
Perioperative cerebral hyperperfusion01
Cerebral hemorrhage and contralateral stroke22
Cardiopulmonary or gastro-intestinal event1417
Cancer and unknown105

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