Literature Review of Primary versus Patching versus Eversion as Carotid Endarterectomy Closure.

Abstract

BACKGROUND\nThe type of closure after carotid endarterectomy (CEA), whether primary, patching or eversion resulting optimal results remains somewhat controversial. This article compares the results of randomized controlled trials (RCT) and systematic/meta-analysis of the various types of closure.\n\n\nMETHODS\nWe conducted a PubMed literature review search comparing CEA with primary closure versus CEA with patching versus eversion CEA over the past three decades with an emphasis on RCTs and previously reported systematic/meta-analysis and large multicenter observational studies (VQI data) or recent single large study center.\n\n\nRESULTS\nResults from Randomized Trials Comparing Primary Patching versus Primary Closure: Most of these randomized trials showed CEA with patching was superior to CEA with primary closure in lowering perioperative stroke rates, stroke/death rates, carotid thrombosis and rate of late restenosis. These studies also showed no significant difference between preferential use of several patch material whether synthetic patches (Dacron, ACUSEAL, PTFE or pericardial patches) or vein (saphenous or jugular) .\n\n\nRESULTS\nfrom Observational Studies Comparing Patching versus Primary Closure: Vascular Study Group of New England data showed that use of patching increased from 71% to 91% (p<.001) and 1 year restenosis/occlusion (p<.01) and 1 year stroke/TIA (p<.03) was statistically lower with patch closure.\n\n\nRESULTS\nfrom Randomized Trials Comparing Eversion CEA versus Conventional CEA: Several randomized trials which compared eversion CEA with conventional CEA, showed equivalency of conventional CEA vs eversion CEA (level 1 evidence) with patching in perioperative carotid thrombosis and stroke rates. At 4 years, post carotid stenosis was lower for eversion CEA vs primary closure (3.6% vs 9.2%, p=.01), but was comparable between patching vs eversion (1.5% for patching vs 2.8% for eversion).\n\n\nCONCLUSIONS\nRoutine carotid patching or eversion CEA was superior to primary closure (level 1 evidence). There was no significant difference between preferential use of several patch material. The rates of significant post CEA stenosis for CEA with patching was similar to eversion CEA and both were superior to primary closure.