Is Routine Patching Necessary Following Carotid Endarterectomy? A 30 Year Experience
Nicholas J. Gargiulo III1, Frank J. Veith2, Evan Lipsitz3, Neal Cayne4.
1Clinch Valley Health, Richlands, VA, USA, 2Cleveland Clinic, Cleveland, OH, USA, 3Montefiore Medical Center, NY, NY, USA, 4NYU, NY, NY, USA.
Background: Large medicare databases and meta-analyses recommend routine patching following carotid endarterectomy (CEA). Routine patching reduces perioperative stroke, carotid thrombosis and restenosis. This 30 year experience evaluates the long term outcome of CEA with selective patching and without routine postoperative duplex evaluation.
Methods: An IRB- approved retrospective review of all CEAs performed by two surgeons over a 30 year period (1984-2014). Pre-operative imaging studies, operative reports, physical findings, co-morbid conditions, and pre- and postoperative medications were evaluated.
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.
Conclusions: In this experience, there is no statistically significant difference in restenosis in the primary closure group and selective patch group following CEA. Although this dataset is a small, single center, two surgeon, retrospective review, it does not support the generally well accepted view of routine patching following CEA.
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