Society For Clinical Vascular Surgery

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Eversion vs Conventional Carotid Endarterectomy in the Vascular Quality Initiative Database
Hanaa Dakour-Aridi, MD1, Michael Ou, BS2, Satinderjit Locham, MD1, Joseph R. Schneider, MD, PhD3, Mahmoud Malas, MD, MHS1
1University of California San Diego, La Jolla, CA, USA, 2Johns Hopkins University School of Medicine, Baltimore, MD, USA, 3Northwestern University Feinberg School of Medicine, Chicago, IL

Introduction: There is still no agreement regarding the optimal technique for performing carotid endarterectomy (CEA). The purpose of this study is to compare the postoperative outcomes and durability of conventional (c-CEA) vs. eversion (e-CEA) in real-world practice.
Methods:We performed a retrospective review of the VQI dataset (2003-2018).Patients with prior ipsilateral carotid intervention and those undergoing concomitant procedures were excluded. Multivariable logistic and Cox-regression analyses were used.
Results:A total of 95,726 CEA cases were included, of which 12,050 (12.6%) were e-CEA.Patch angioplasty was used in 94.9% of c-CEA compared with 49.7% of e-CEA(P<0.001).On univariable analysis, no difference in perioperative outcomes was noted between the two approaches except for higher rates of in-hospital dysrhythmia (1.5% vs.1.3%),post-procedural hemodynamic instability (27.3% vs.24.3%) and cranial nerve injury(3.2% vs.2.2%) after c-CEA vs. e-CEA (All p<0.05).On the other hand, e-CEA patients were more likely to return to the OR (RTOR) for bleeding (1.3% vs.c-CEA:0.9%,p<0.001)(Table 1).The outcomes of e-CEA didnít differ if a patch was used or not. After adjusting for potential confounders and stratifying with respect to patch use, there was no difference in terms of in-hospital bleeding, 30-day stroke/death and restenosis and stroke/death at 2-years between e-CEA and c-CEA when a patch is used. However, when no patching was performed,e-CEA was associated with lower stroke/death at 30-days (OR:0.72,95%CI:0.54-0.95) and at 2-years (HR: 0.77,95%CI:0.61-0.97)(Table 2). Sensitivity analysis of the gold-standard approaches (e-CEA without patching vs.c-CEA with patching) showed similar stroke/death and restenosis rates between the two techniques However, e-CEA was associated with 42% higher odds of RTOR for bleeding compared to c-CEA(Table 2).
Conclusion: This study shows significant variability in the technique of e-CEA across the US. Both e-CEA and c-CEA are safe and durable techniques with similar stroke/death and restenosis rates up to 2-years of follow up, as long as c-CEA is performed with patch angioplasty. However, e-CEA is superior to c-CEA without patch angioplasty, and is associated with 28% and 23% reduction in the odds of 30-day and 2-year stroke/death, respectively.

Conventional CEAEversion CEAP Value
In-Hospital Outcomes
Death232 (0.3)31 (0.3)0.70
Ipsilateral Cortical629 (0.8)84 (0.7)0.52
Stroke826 (1.2)124 (1.2)0.90
Stroke/Death987 (1.2)145 (1.2)0.82
Stroke/Death/MI1,556 (1.9)221 (1.8)0.85
Myocardial Infarction664 (0.8)82 (0.7)0.19
Dysrhythmia1,290 (1.5)150 (1.3)0.01
Post-procedural Hemodynamic Instability22,777 (27.3)2,922 (24.3)<0.001
Surgical Site Infection42 (0.1)7 (0.1)0.72
Reperfusion Syndrome127 (0.2)26 (0.2)0.10
Cranial Nerve Injury2,682 (3.2)265 (2.2)<0.001
Immediate Re-exploration (For defect detected after closure during same operation)1,336 (1.6)222 (1.8)0.05
Return OR for Bleeding763 (0.9)157 (1.3)<0.001
Return OR for Neurologic Causes341 (0.4)60 (0.5)0.15
Operative time in minutes, Mean (SD)116.0 (43.5)109.3 (46.0)<0.001
Thirty-Day Outcomes
Ipsilateral Stroke713 (1.4)89 (1.2)0.06
Stroke950 (1.9)138 (1.8)0.51
Death550 (0.7)76 (0.6)0.74
Stroke/Death1,393 (1.7)198 (1.6)0.87
Repeat Revascularization1,568 (3.1)274 (3.5)0.06

Multivariable Logistic Regression
Overall Cohort
c-CEAe-CEA
N=83,726N=12,050
OR/HR (95%CI)OR/HR (95%CI)p-value
Return to OR for bleedingRef.1.32 (1.04-1.67)0.02
30-day Stroke/DeathRef.0.87 (0.73-1.04)0.12
2-Year Stroke/DeathRef.0.94 (0.82-1.10)0.50
2-Year RestenosisRef.0.92 (0.76-1.11)0.36
Without Patching
c-CEAe-CEA
N=4,288N=6,055
OR/HR (95%CI)OR/HR (95%CI)p-value
Return to OR for bleedingRef.1.43 (0.89-2.29)0.14
30-day Stroke/DeathRef.0.72 (0.54-0.95)0.02
2-Year Stroke/DeathRef.0.77 (0.61-0.97)0.03
2-Year RestenosisRef.0.94 (0.70-1.27)0.70
With Patching
c-CEAe-CEA
N=79,351N=5,992
OR/HR (95%CI)OR/HR (95%CI)p-value
Return to OR for bleedingRef.1.30 (0.98-1.73)0.07
30-day Stroke/DeathRef.0.94 (0.76-1.16)0.58
2-Year Stroke/DeathRef.1.05 (0.87-1.25)0.63
2-Year RestenosisRef.0.93 (0.73-1.19)0.56
c-CEA with Patchinge-CEA without Patching
N=79,351N=6,055
OR/HR (95%CI)OR/HR (95%CI)p-value
Return to OR for bleedingRef.1.42 (1.06-1.91)0.02
30-day Stroke/DeathRef.1.27 (0.99-1.64)0.06
2-Year Stroke/DeathRef.0.98 (0.82-1.18)0.85
2-Year RestenosisRef.1.14 (0.94-1.39)0.19

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