A technical modification of carotid endarterectomy experience with 400 patients

1. A Technical Modification Of CarotidA Technical Modification Of Carotid
EndEndarterectomy - Experience With 400arterectomy - Experience With 400
PatientsPatients
Faik Fevzi OkurFaik Fevzi Okur
Sifa University Cardiovascular Surgery Dept.Sifa University Cardiovascular Surgery Dept.
Izmir / TURKEYIzmir / TURKEY
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2. Surgical Technique 1Surgical Technique 1
Neurosurg Focus.Neurosurg Focus. 2008;24(2):E182008;24(2):E18.. LinksLinks
 Techniques in carotid artery surgeryTechniques in carotid artery surgery..
 Curtis JACurtis JA,, Johansen KJohansen K..
 Swedish Neuroscience Institute and Swedish Medical Center, Cherry Hill Campus Seattle, Washington,Swedish Neuroscience Institute and Swedish Medical Center, Cherry Hill Campus Seattle, Washington,
USA. curtis_ja@yahoo.com.auUSA. curtis_ja@yahoo.com.au
 The major objective in carotid endarterectomy is to achieveThe major objective in carotid endarterectomy is to achieve
safe and complete removal of intimal plaque and providesafe and complete removal of intimal plaque and provide
lasting, nonstenotic closurelasting, nonstenotic closure. Controversy exists as to which technical variation best. Controversy exists as to which technical variation best
achieves this. In this paper, the authors review the operative nuances and outcomes with conventionalachieves this. In this paper, the authors review the operative nuances and outcomes with conventional
and eversion endarterectomyand eversion endarterectomy,, with a focus on the latter. The views expressed reflect specific neurosurgical and vascularwith a focus on the latter. The views expressed reflect specific neurosurgical and vascular
perspectives in the context of a multi-disciplinary stroke unit, where carotid stenosis is managed with all available open andperspectives in the context of a multi-disciplinary stroke unit, where carotid stenosis is managed with all available open and
endovascular means. The neurosurgical approach was almost entirely conventional endarterectomy with primary repair, while theendovascular means. The neurosurgical approach was almost entirely conventional endarterectomy with primary repair, while the
vascular surgeons used the eversion method with few exceptions.vascular surgeons used the eversion method with few exceptions.
 PMID: 18275295 [PubMed - in process]PMID: 18275295 [PubMed - in process]
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3. Surgical Technique 2Surgical Technique 2
 J Vasc Surg. 2001 Sep;34(3):453-8.J Vasc Surg. 2001 Sep;34(3):453-8. LinksLinks
 Durability of eversion carotid endarterectomy: comparison withDurability of eversion carotid endarterectomy: comparison with
primary closure and carotid patch angioplastyprimary closure and carotid patch angioplasty..
 Katras TKatras T,, Baltazar UBaltazar U,, Rush DSRush DS,, Sutterfield WCSutterfield WC,, Harvill LMHarvill LM,, Stanton PE JrStanton PE Jr..
 Department of Surgery, Division of Vascular Surgery, James H. Quillen College of Medicine, East Tennessee State University, Johnson City 37604, USA. katras@etsu.eduDepartment of Surgery, Division of Vascular Surgery, James H. Quillen College of Medicine, East Tennessee State University, Johnson City 37604, USA. katras@etsu.edu
 OBJECTIVES: Despite numerous studies in which various methods for arteriotomy closure after carotid endarterectomy (CEA) have been addressed, the optimum surgical techniqueOBJECTIVES: Despite numerous studies in which various methods for arteriotomy closure after carotid endarterectomy (CEA) have been addressed, the optimum surgical technique
to reduce complications and late carotid restenosis has yet to be firmly established. The purpose of this study was to prospectively compare the results of the eversion CEA techniqueto reduce complications and late carotid restenosis has yet to be firmly established. The purpose of this study was to prospectively compare the results of the eversion CEA technique
with those of conventional CEA with either primary closure or carotid patch angioplasty, and to determine under clinical conditions whether eversion CEA influences the results andwith those of conventional CEA with either primary closure or carotid patch angioplasty, and to determine under clinical conditions whether eversion CEA influences the results and
restenosis rate.Patients and Methods: Over a 3-year period, 322 CEAs performed on 296 consecutive patients were concurrently evaluated. This study included 118 eversion CEAs, 97restenosis rate.Patients and Methods: Over a 3-year period, 322 CEAs performed on 296 consecutive patients were concurrently evaluated. This study included 118 eversion CEAs, 97
CEAs with primary closure, and 107 CEAs with patch angioplasty. There were no differences in demographics, in surgical indications, or in the severity of carotid disease (notCEAs with primary closure, and 107 CEAs with patch angioplasty. There were no differences in demographics, in surgical indications, or in the severity of carotid disease (not
significant [NS]). The choice of CEA technique was not randomized because of technical considerations and surgeon preference. After entry into the protocol, no patients weresignificant [NS]). The choice of CEA technique was not randomized because of technical considerations and surgeon preference. After entry into the protocol, no patients were
excluded or withdrawn. Carotid restenosis was defined as a > 60% lumen reduction at the CEA site with established duplex ultrasonography criteria. RESULTS: The mean operativeexcluded or withdrawn. Carotid restenosis was defined as a > 60% lumen reduction at the CEA site with established duplex ultrasonography criteria. RESULTS: The mean operative
time for eversion CEA was 31 minutes, for CEA-primary closure it was 39 minutes, and for CEA-patch angioplasty it was 46 minutes (P <.01). The operative mortality rate for eversiontime for eversion CEA was 31 minutes, for CEA-primary closure it was 39 minutes, and for CEA-patch angioplasty it was 46 minutes (P <.01). The operative mortality rate for eversion
CEA was 0.8% (1 patient), for CEA-primary closure it was 1.0% (1 patient), and for CEA-patch angioplasty it was 2.8% (3 patients) (NS). The postoperative stroke rate was 0.8% afterCEA was 0.8% (1 patient), for CEA-primary closure it was 1.0% (1 patient), and for CEA-patch angioplasty it was 2.8% (3 patients) (NS). The postoperative stroke rate was 0.8% after
eversion CEA, 1.0% after CEA-primary closure, and 2.8% after CEA-patch angioplasty (NS). The combined stroke and death rate in each group was thus 0.8% for eversion CEA (1eversion CEA, 1.0% after CEA-primary closure, and 2.8% after CEA-patch angioplasty (NS). The combined stroke and death rate in each group was thus 0.8% for eversion CEA (1
stroke-death), 1% for CEA with primary closure (1 stroke-death), and 5% for CEA with patch angioplasty (1 stroke-death, 2 fatal myocardial infarctions, and 2 nonfatal strokes) (NS).stroke-death), 1% for CEA with primary closure (1 stroke-death), and 5% for CEA with patch angioplasty (1 stroke-death, 2 fatal myocardial infarctions, and 2 nonfatal strokes) (NS).
Transient ischemic attacks occurred in 2.5% after eversion CEA, in 5.2% after CEA-primary closure, and in 2.9% with CEA-patch angioplasty (NS). The mean clinical follow-up for allTransient ischemic attacks occurred in 2.5% after eversion CEA, in 5.2% after CEA-primary closure, and in 2.9% with CEA-patch angioplasty (NS). The mean clinical follow-up for all
three groups was 23 months (range, 6-42 months) (NS). The restenosis rate was 1.7% after eversion CEA, 9.3% after CEA-primary closure, and 6.5% after CEA-patch angioplasty (Pthree groups was 23 months (range, 6-42 months) (NS). The restenosis rate was 1.7% after eversion CEA, 9.3% after CEA-primary closure, and 6.5% after CEA-patch angioplasty (P
<.05). CONCLUSIONS: This prospective, nonrandomized clinical study indicates that eversion CEA is an effective surgical option comparable to conventional CEA with either<.05). CONCLUSIONS: This prospective, nonrandomized clinical study indicates that eversion CEA is an effective surgical option comparable to conventional CEA with either
primary arteriotomy closure or carotid patch angioplasty. No differences were found between eversion CEA and these more widely accepted CEA closure techniques with respect toprimary arteriotomy closure or carotid patch angioplasty. No differences were found between eversion CEA and these more widely accepted CEA closure techniques with respect to
operative morbidity and mortalityoperative morbidity and mortality.. These data indicate, however, that eversion CEA has aThese data indicate, however, that eversion CEA has a
lower restenosis rate than conventional CEA closure techniques and thuslower restenosis rate than conventional CEA closure techniques and thus
superior long-term durabisuperior long-term durabilitylity..
 PMID: 11533597 [PubMed - indexed for MEDLINE]PMID: 11533597 [PubMed - indexed for MEDLINE]
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4.  J Vasc Surg. 2005 Nov;42(5):870-7.J Vasc Surg. 2005 Nov;42(5):870-7.
 Primary closure of the carotid artery is associated with poorer outcomesPrimary closure of the carotid artery is associated with poorer outcomes
during carotid endarterectomy.during carotid endarterectomy.
 Rockman CBRockman CB,, Halm EAHalm EA,, Wang JJWang JJ,, Chassin MRChassin MR,, Tuhrim STuhrim S,, Formisano PFormisano P,, Riles TSRiles TS..
 Department of Surgery, New York University School of Medicine, NY 10016, USA. caron.rockman@nyumc.orgDepartment of Surgery, New York University School of Medicine, NY 10016, USA. caron.rockman@nyumc.org
 INTRODUCTION: Arterial endarterectomy and reconstruction during carotid endarterectomy (CEA) can be performed in a variety of ways,INTRODUCTION: Arterial endarterectomy and reconstruction during carotid endarterectomy (CEA) can be performed in a variety of ways, including standardincluding standard
endarterectomy with primary closure, standard endarterectomy with patch angioplasty, and eversion endarterectomyendarterectomy with primary closure, standard endarterectomy with patch angioplasty, and eversion endarterectomy. The optimal method of arterial reconstruction. The optimal method of arterial reconstruction
remains a matter of controversy. The objective of this study was to determine the effect of the method of arterial reconstruction during CEA on perioperativeremains a matter of controversy. The objective of this study was to determine the effect of the method of arterial reconstruction during CEA on perioperative
outcome. METHODS: A retrospective cohort study of consecutive CEAs performed by 81 surgeons during 1997 and 1998 in six regional hospitals was performed.outcome. METHODS: A retrospective cohort study of consecutive CEAs performed by 81 surgeons during 1997 and 1998 in six regional hospitals was performed.
Detailed clinical data regarding each case and all deaths and nonfatal strokes within 30 days of surgery were ascertained by an independent review of the inpatientDetailed clinical data regarding each case and all deaths and nonfatal strokes within 30 days of surgery were ascertained by an independent review of the inpatient
chart, outpatient surgeon record, and the hospitals' administrative databases. Two physician investigators--one neurologist and one internist--confirmed each adversechart, outpatient surgeon record, and the hospitals' administrative databases. Two physician investigators--one neurologist and one internist--confirmed each adverse
event by independently reviewing patients' medical records.event by independently reviewing patients' medical records.

RESULTS:RESULTS: A total of 1972 CEAs were performedA total of 1972 CEAs were performed. The mean age of the patients was 72.3 years, and 57.2% were male.. The mean age of the patients was 72.3 years, and 57.2% were male.
Preoperative neurologic symptoms occurred in 28.7% of cases (n = 566), and the remaining 71.3% were asymptomatic before surgery (n = 1406). The method ofPreoperative neurologic symptoms occurred in 28.7% of cases (n = 566), and the remaining 71.3% were asymptomatic before surgery (n = 1406). The method of
arterial reconstruction was chosen by the surgeon. Primary closure was performed in 11.8% (n = 233), patch angioplasty in 69.8% (n = 1377), and eversionarterial reconstruction was chosen by the surgeon. Primary closure was performed in 11.8% (n = 233), patch angioplasty in 69.8% (n = 1377), and eversion
endarterectomy in 18.4% (n = 362). There was no significant difference in the preoperative symptom status of patients who underwent primary closure comparedendarterectomy in 18.4% (n = 362). There was no significant difference in the preoperative symptom status of patients who underwent primary closure compared
with the other methods of reconstruction (72.5% asymptomatic vs 71.1%, p = NS). Primary closure cases were significantly more likely to experience perioperativewith the other methods of reconstruction (72.5% asymptomatic vs 71.1%, p = NS). Primary closure cases were significantly more likely to experience perioperative
stroke compared with the other closure techniques (5.6% vs 2.2%, P = .006). Primary closure cases also had a higher incidence of perioperative stroke or deathstroke compared with the other closure techniques (5.6% vs 2.2%, P = .006). Primary closure cases also had a higher incidence of perioperative stroke or death
compared with the other closure techniques (6.0% vs 2.5%, P = .006). There were no significant differences with regard to either perioperative stroke, orcompared with the other closure techniques (6.0% vs 2.5%, P = .006). There were no significant differences with regard to either perioperative stroke, or
perioperative stroke/death noted when comparing patch angioplasty with eversion endarterectomy: stroke, 2.2% vs 2.5% (P = NS) and stroke/death, 2.5% vs 2.5%perioperative stroke/death noted when comparing patch angioplasty with eversion endarterectomy: stroke, 2.2% vs 2.5% (P = NS) and stroke/death, 2.5% vs 2.5%
(P = NS) respectively. CONCLUSION: It appears that primary closure is associated with significantly worse perioperative outcomes compared with endarterectomy(P = NS) respectively. CONCLUSION: It appears that primary closure is associated with significantly worse perioperative outcomes compared with endarterectomy
with patch angioplasty and eversion endarterectomy, even when the preoperative symptom status of the patient cohorts is equivalent. Although some of its advocateswith patch angioplasty and eversion endarterectomy, even when the preoperative symptom status of the patient cohorts is equivalent. Although some of its advocates
have reported that they can properly select appropriate patients for primary closure based on the size of the artery and other factors, the data demonstrate that thesehave reported that they can properly select appropriate patients for primary closure based on the size of the artery and other factors, the data demonstrate that these
patients have poorer outcomes nonetheless.patients have poorer outcomes nonetheless. Primary closure during carotid endarterectomy shouldPrimary closure during carotid endarterectomy should
predominantly be abandoned in favor of either standard endarterectomy withpredominantly be abandoned in favor of either standard endarterectomy with
patch angioplasty or eversion endarterectomy.patch angioplasty or eversion endarterectomy.
Surgical Technique 3Surgical Technique 3
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7. Demography of the patientsDemography of the patients
Mean Age Male % DM % HT % Smoking PAD
Asymptomatic
(n:126)
62,2±6,7 77,1 45,5 63,2 25,9 13,5
Symptomatic
(n: 232)
63,1±4,1 68,3 26,3 42,2 26,5 8,08
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22. Left CEA post op 42. month.Left CEA post op 42. month.
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23. Left CEA post op 36. month.Left CEA post op 36. month.
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24. Left CEA post op 36. month.Left CEA post op 36. month.
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25. Right CEA post op. 36. Month.Right CEA post op. 36. Month.
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