Carotid patch angioplasty: immediate and long-term results

To determine the benefit of carotid patch angioplasty, a retrospective study of 1000 consecutive carotid endarterectomies was done. Based on the type of carotid endarterectomy closure, patients were divided into four groups: 250 had primary closure, 250 had expanded polytetrafluoroethylene patch, 250 had Dacron patch, and 250 had saphenous vein patch. On the basis of operative technique or type of carotid artery closure, no statistical difference was found in the incidence of postoperative stroke (p greater than 0.25): primary closure 1.6% (4), expanded polytetrafluoroethylene 2.0% (5), Dacron patch 1.6% (4), and saphenous vein patch (0). Postoperative carotid patency was determined by B-mode ultrasonography, and 717 patients were evaluated in follow-up extending to 6 years (mean 37.8 months). Based on the method of carotid endarterectomy closure, no significant difference (p greater than 0.25) was found in the incidence of significant restenosis (greater than 50% diameter reduction): primary closure 4.0% (7), expanded polytetrafluoroethylene 4.0% (6), Dacron 5.4% (9), and saphenous vein 1.0% (2). Significant restenosis was most frequent in habitual smokers (93%, 25/28) and females (78%, 22/28) despite the method of carotid endarterectomy closure. No statistical difference was found in the incidence of late ipsilateral stroke either (p greater than 0.25): primary closure 2.9% (5), expanded polytetrafluoroethylene 2% (3), Dacron 5% (3), and saphenous vein 0%. These results indicate that the incidence of postoperative stroke, regardless of method of arterial closure, was not statistically different. The method of carotid closure did not appear to affect the occurrence of late ipsilateral stroke or restenosis; however, patch angioplasty with saphenous vein appears appropriate in habitual smokers, and likely in patients with small internal carotid arteries.     

Early and late geometric changes after carotid endarterectomy patch reconstruction

This study examines the degree and location of vessel wall geometric changes after carotid endarterectomy-vein patch reconstruction. The external diameters of the proximal common carotid, common carotid bulb, and internal carotid arteries were measured during operation with a caliper after 349 carotid endarterectomies. There were 309 saphenous vein reconstructions, 31 synthetic patch reconstructions, and 9 primary closures. One or more B-mode ultrasound studies with cross-sectional views for common and internal carotid cursor measurements were performed from 3 months to 5 years after operation. The intraoperative-to-postoperative common carotid diameters were unchanged for the three types of reconstructions. The internal carotid diameters increased 20% to 30% for both the vein and synthetic patched arteries. This dilation was present at 3 and 6 months and progressed slightly over 5 years. Wall thickening greater than or equal to 1 mm was present in 62% of the carotid endarterectomies, with concentric stenosis in 3% and eccentric stenosis in 59%. Eccentric stenosis was present at 3 to 6 months, located on the endarterectomized posterior-medial wall of the common and internal carotid arteries, was always less than 50%, and changed very little over 5 years. No aneurysms or internal carotid occlusions were identified. Carotid endarterectomy-vein patch reconstruction results in early, mild, nonaneurysmal dilation of the internal carotid patched segment, frequent mild eccentric restenosis, and rare hemodynamically significant concentric restenosis.     

Prospective randomized trial of carotid endarterectomy with primary closure and patch angioplasty with saphenous vein, jugular vein, and polytetrafluoroethylene: Perioperative (30-day) results

Purpose: The early outcomes of carotid endarterectomy (CEA) with primary closure (PC) versus vein patch closure (saphenous vein [SVP] and jugular vein [JVP]) and polytetrafluoroethylene patch closure (PTFE-PC) were compared.Methods: Three hundred ninety-nine CEAs were randomized into the following groups: 135 PC, 134 PTFE-PC, and 130 vein patch closure (SVP alternating with JVP). Surviving patients underwent a carotid color duplex ultrasonographic scan 1 month after surgery. Demographic characteristics were similar in all groups.Results: The incidence of perioperative cerebrovascular accidents (CVAs) was 4.4% for PC, 0.8% for PTFE-PC, and 0% for vein patch closure (PC vs vein patch, p = 0.0165; PC vs all patching [vein and PTFE], p = 0.007). The perioperative CVA and reversible ischemic neurologic deficit (RIND) combined rates for all patching were superior to PC (1.5% vs 5.2%; p = 0.04). These combined rates were also superior for vein patch closure when compared with PC (0.8% vs 5.2%; p = 0.037). The mean diameter of the internal carotid artery was similar in patients who had perioperative neurologic deficits and those who did not. After 1 month of follow-up, 11.9% of the PC arteries were narrowed 50% or more in contrast to 2.3% for PTFE-PC, 3.1% for SVP, and 10.3% for JVP (PC vs all patching, p = 0.008; PC vs PTFE-PC, p = 0.0017; PC vs SVP, p = 0.028). In contrast, early postoperative dilation of the internal carotid artery to more than twice the measured diameter was not significantly higher in patched arteries than in PC arteries. The mean operative and hemostasis times were significantly longer for patching than for PC.Conclusions: Patch closure is less likely than PC to cause perioperative CVA, RIND, and early internal carotid artery stenosis. (J Vasc Surg 1996;24;998-1007.)     

Double-layer everted saphenous vein patch angioplasty for carotid endarterectomy

Saphenous vein patch angioplasty is the preferred method of closure of the arteriotomy site during carotid endarterectomies. A major early complication of the saphenous vein patch is rupture of the patch which can occur within the first few postoperative days. The reported incidence varies from 0.5% to 4%. Patch rupture can result in stroke or death. From May 1992 to April 1999, autogenous everted double-layer saphenous vein patch was used in 192 carotid endarterectomies performed on 168 patients; 96 males and 72 females. The age range was from 54 to 94 years with a mean age of 73 years. The saphenous vein is harvested from the ankle. It is everted and then used as a double-layer patch. The follow-up period was from 3 to 74 months, with a mean of 24 months. Postoperatively, there were no patch ruptures or late aneurysm formation. There was no perioperative mortality. Everted double-layer saphenous vein patch eliminates the risk of patch rupture and at the same time retains the benefits of an autologous nonprosthetic graft. Saphenous vein from the ankle can be safely used for carotid angioplasty as a double layer patch.     

Vein patch versus primary closure for carotid endarterectomy. A randomized prospective study in a selected group of patients

During a 4-year period, 136 patients undergoing 152 carotid endarterectomies consented to be randomized to primary or saphenous vein patch closure of the arteriotomy. At operation, before randomization, careful assessment of arterial dimensions and anatomy was made. Patients who had an internal carotid artery (ICA) diameter less than 5 mm, arteriotomy extending more than 3 cm beyond the origin of the ICA, or tortuous or kinked ICAs were not randomized; they received obligatory vein patch closure (necessary in 20% cases). All patients were followed up every 3 months for 1 year and every 6 months thereafter with duplex scanning, ocular pneumoplethysmography, and neurologic assessment. The incidence of atherosclerotic risk factors was equal in the groups and all except one of the patients were male. Perioperative morbidity was not significantly different among those having primary closure (n = 60), saphenous vein patch closure (n = 62), and obligatory vein patch closure (n = 30). Operative time among patients having primary closure (122 +/- 4 minutes) was significantly less (p less than 0.001) than among those having saphenous vein patch closure (150 +/- 3 minutes). Three perioperative strokes were evenly distributed among the groups (2% for all procedures); no deaths and no acute postoperative occlusions occurred. Recurrent disease occurred in 12.9% of patients having saphenous vein patch closure compared with its occurrence in 1.7% of those having primary closure (p less than 0.05). However, most recurrences were moderate stenoses (25% to 50% diameter reduction), all were smooth-surfaced, and none required a second operation. All except one of the recurrences among those patients with saphenous vein patch closure were in the bulb and the origin of the ICA; two had evidence of regression. This finding suggested that thrombus layering in the dilated part of the saphenous vein patch reconstruction was the cause. This study demonstrates that in men with carotid arteries of predetermined minimal dimensions undergoing carotid endarterectomy routine saphenous vein patch closure does not produce superior results, is associated with a higher incidence of early recurrence, and increases operative time. In selected patients with anatomic risk factors for recurrent disease or acute postoperative occlusion, saphenous vein patch closure is appropriate.     

A comparative study of saphenous vein,internal jugular vein,and knitted dacron patches for carotid artery endarterectomy

To determine whether the choice of material used for patch closure following carotid artery endarterectomy (CAE) affected the immediate operative results, the early follow-up results, or the incidence of early restenosis, a retrospective study of 275 consecutive carotid endarterectomies by two vascular surgeons was performed. Among 275 primary CAEs performed between July 1991 and August 1993, 159 (57.8%) were closed with saphenous vein (SV), 25 (9.1%) with double-thickness internal jugular vein (JV), and 91 (33.1%) with knitted Dacron (KD). Primary closure was not used in any of the arteries in this series. The overall perioperative mortality rate was 1.1% and the rate of major and minor morbidity was 4.4%. There were four (1.5%) perioperative strokes: two (1.3%) in the SV group, one (4.0%) in the JV group, and one (1.1%) in the KD group. Two-hundred fifty-eight (93.8%) of the 275 endarterectomies were followed postoperatively for 2 to 35 months (mean 14.4). Two-hundred nineteen (79.6%) were evaluated using duplex scans during follow-up with a mean interval of 13.7 months. Of the arteries studied, four (3.6%) in the SV group, none in the JV group, and six (8.4%) in the KD group demonstrated restenosis of >50% at the time of follow-up (NS). In addition, one (0.9%) artery in the SV group, one (5.6%) in the JV group, and none in the KD group demonstrated complete occlusion. Retrospective analysis of the data showed no statistically significant differences in perioperative morbidity, mortality, or early postoperative restenosis whether the artery was closed with saphenous vein, jugular vein, or knitted Dacron patches. Longer follow-up is needed to determine whether rates of late restenosis and aneurysmal dilatation will differ between synthetic and autologous patches.Presented at the Nineteenth Annual Meeting of the Peripheral Vascular Surgery Society, Seattle, Wash., June 5, 1994.     

Systematic review of randomized controlled trials of patch angioplasty versus primary closure and different types of patch materials during carotid endarterectomy

BACKGROUND: Patch angioplasty during carotid endarterectomy (CEA) may reduce the risk for perioperative or late carotid artery recurrent stenosis and subsequent ischemic stroke. We performed a systematic review of randomized controlled trials to assess the effect of routine or selective carotid patch angioplasty compared with CEA with primary closure, and the effect of different materials used for carotid patch angioplasty. METHODS: Randomized trials were included if they compared carotid patch angioplasty with primary closure in any patients undergoing CEA or use of one type of carotid patch with another. RESULTS: Thirteen eligible randomized trials were identified. Seven trials involving 1281 operations compared primary closure with routine patch closure, and 8 trials with 1480 operations compared different patch materials (2 studies compared both). Patch angioplasty was associated with a reduction in risk for stroke of any type (P = .004), ipsilateral stroke (P = .001), and stroke or death during both the perioperative period (P = .007) and long-term follow-up (P = .004). Patching was also associated with reduced risk for perioperative arterial occlusion (P = .0001) and decreased recurrent stenosis during long-term follow-up (P < .0001). Seven trials that compared different patch types showed no difference in the risk for stroke, death, or arterial recurrent stenosis either perioperatively or at 1-year follow-up. One study of 180 patients (200 arteries) compared collagen-impregnated Dacron (Hemashield) patches with polytetrafluoroethylene patches. There was a significant increase in risk for stroke (P = .02), combined stroke and transient ischemic attack (P = .03), and recurrent stenosis (P = .01) at 30 days, and an increased risk for late recurrent stenosis greater than 50% (P < .001) associated with Dacron compared with polytetrafluoroethylene. CONCLUSIONS: Carotid patch angioplasty decreases the risk for perioperative death or stroke, and long-term risk for ipsilateral ischemic stroke. More data are required to establish differences between various patch materials.     

Autogenous common facial vein or external jugular vein patch for carotid endarterectomy.

BACKGROUND: The purpose of this study was to determine whether common facial vein or external jugular vein are as good a vein patch as a saphenous vein for carotid patch angioplasty. METHOD: Retrospectively, 19 patients who underwent everted common facial vein or external jugular vein patch were compared with 199 patients who underwent saphenous vein patch carotid endarterectomy during 1989 to 1996. The two groups were compared clinically and by sonographic surveillance. The mean follow-up was 18+/-4 months for common facial vein/external jugular vein patients and 48+/-15 months for saphenous vein patch group. RESULTS: No significant differences in mortality or morbidity were observed among patients in whom everted common facial vein or external jugular vein was used as compared with saphenous vein. No bleeding, thrombotic event, dilation of the patch or aneurysmal degeneration and perioperative deaths occurred in either of the two groups. Duplex surveillance studies showed no significant difference in recurrent moderate (50-79%) and severe (80-99%) stenosis. CONCLUSION: Everted common facial vein or external jugular vein patch was comparable to other vein patches. This eliminates the comorbidity of groin incision. Also, using everted common facial vein or external jugular vein as vein patch saves saphenous vein to be used for other vascular procedures, such as coronary artery or lower extremity bypass.     

Rupture of the vein patch: a rare complication of carotid endarterectomy

Vein patch closure after carotid endarterectomy has been used to reduce the incidence of residual and recurrent stenosis at the carotid bifurcation. A rare but potential serious complication is rupture of the vein patch during the early postoperative period. In our experience of 2359 carotid operations performed from 1962 through 1986, saphenous vein was used for closure in 2275 (96.5%) operations. In three patients out of 75 in whom the vein patch had been harvested from the ankle, rupture of the patch occurred 2 to 5 days after uneventful carotid surgery. At emergency reoperation, the central portion of the vein was necrotic, with no evidence of infection. In each case the carotid artery was closed again with fresh thigh saphenous vein, and recovery was uneventful. The use of ankle vein was discontinued in December 1983 in favor of groin saphenous vein, and similar complications have not occurred in more than 600 carotid endarterectomies performed since. Early noninfectious ruptures of the saphenous vein patches have been mentioned in other reported series of carotid operations and have often been related to the use of ankle vein, but they remain unexplained.     

Carotid bifurcationplasty: an alternative to patching.

Patching of carotid endarterectomies has been advocated as a means of both facilitating secure closure and minimizing recurrent stenosis. Most vascular surgeons occasionally, if not always, patch selected carotid arteries. However, patching requires the surgeon to utilize either prosthetic material (Dacron or PTFE), which is relatively thrombogenic, or autogenous vein, which requires a second operative field and available saphenous vein at the ankle. Bifurcationplasty, otherwise known as bifurcation advancement, has been used as an alternative to patching at our institution over the past four years. This technique, which involves the use of the opened, endarterectomized external carotid artery as an autogenous in-continuity patch for the internal carotid artery, obviates the need for prosthetic materials and saphenous vein alike. This procedure has been performed 30 times over a 4-year period (1987-91). During this time, 280 carotid endarterectomies were performed. A vein patch or Dacron was used in four cases early in this series. Bifurcationplasty was also the procedure of choice for repeat carotid endarterectomy, and was performed in five cases of recurrent stenosis after direct closure. In a follow-up period averaging 22 months (range 1-48), there were no instances of symptomatic restenosis. We feel that bifurcationplasty is an easily performed autogenous alternative to conventional patch closure of the carotid artery.     

Patch closure improves results with carotid endarterectomy

The type of closure after a carotid endarterectomy, primary closure versus patch angioplasty, is controversial. Most authorities agree that in a small carotid artery (相似文献   

A clinical comparison of Dacron patch closure of small-caliber carotids compared with primary closure of large-caliber carotids after endarterectomy

The objective was to study results of carotid endarterectomies performed between 1975 and 1991, comparing primary closure to Dacron patch closure. This was a retrospective study. Data from patient follow-up by physical examination, chart review, and Duplex study were used. Scan data were obtained in 92 of the primary cases, at a mean of 5 years postoperatively, and in 63 of the patch cases, at a mean of 4.1 years postoperatively. During this period, 269 endarterectomies were closed primarily and 101 were closed with a knitted Dacron patch. Twenty patients in the primary group and nine patients with patch closure were lost to follow-up, which extended for up to 12.5 years, with a mean of 4.7 +/- 3.6 years. No acute closures, infections or aneurysms developed in either group. Perioperative stroke incidence was 4.1 per cent for primary closure and 3.0 per cent for the patch group (P > 0.05). Late stenosis occurred in 17.3 per cent of the primary group and 11.1 per cent of the patch closure group (P > 0.05). Five-year survival was 76.2 per cent in the primary group, compared with 79.2 per cent for patch closure. Late stroke incidence was 2.8 per cent in the primary group and 3.3 per cent in the patch closure group. Results of smaller (< or = 3.5 mm) carotid arteries closed with knitted Dacron patches are equivalent to those of larger carotid arteries closed primarily.     

Expanded polytetrafluoroethylene patch angioplasty in carotid endarterectomy

Purpose: This study retrospectively reviewed the experience with expanded polytetrafluoroethylene (ePTFE) patches for carotid endarterectomy in 924 consecutive procedures (753 patients) during a 17-year period.Methods: The records of all patients who underwent ePTFE patch angioplasty for carotid artery stenosis performed by one surgeon were reviewed. The criterion for surgery was stenosis of 80% or greater. Follow-up by use of noninvasive methods was done by 6 months after operation the first year and annually thereafter. Recurrent stenosis was confirmed with angiography. Life-table analysis was used to estimate the risk of restenosis.Results: Early morbidity and mortality included six deaths (0.6%), seven nonfatal strokes (0.9%), and 19 hemorrhages. Two postoperative infections occurred. There were no important aneurysmal dilations and no late hemorrhages. With a mean follow-up of 41.4 months (range 0 to 197), recurrent stenosis necessitating reoperation developed in 28 patients (3.7%). There were two late strokes. Life-table analysis indicated a 89% probability of freedom from stenosis at 120 months.Conclusions: In cases in which the decision to perform patch angioplasty is made at surgery, an ePTFE patch is an excellent alternative to autogenous saphenous vein, with a low rate of recurrences requiring operation and acceptable rates of perioperative and postoperative morbidity and mortality. (J VASC SURG 1995;22:724-31.)     

Everted cervical vein for carotid patch angioplasty

Because of the theoretic benefits of autologous vein we undertook an investigation to evaluate cervical veins (facial, external jugular) as patch material after carotid endarterectomy. A device that stimulated both circumferential fixation by sutures and radial tension exerted on in vivo patches was constructed to measure burst strength of tissue. Mean bursting pressure for groin saphenous vein (n = 10) was 94.5 +/- 15.1 pounds per square inch (psi), 75.5 +/- 8.9 psi for ankle saphenous vein (n = 10), 83.3 +/- 14.5 psi for everted (double layer) cervical vein (n = 5) and 10 +/- 3.3 psi for single layer cervical vein (n = 5). No significant differences between saphenous vein at any level and everted (double layer) cervical vein, but all were significantly different from single layer cervical vein (p less than 0.05). From June 1987 through November 1989, 19 patients underwent 21 carotid endarterectomies complemented with adjunctive everted cervical vein patch angioplasty. Indications for surgery were asymptomatic stenosis (53%), transient ischemic attack (29%), and cerebrovascular accident with recovery (18%). All patients were studied after surgery with duplex scanning. Asymptomatic recurrent stenosis was observed in one patient. Transient hypoglossal nerve dysfunction occurred in one other patient. One postoperative death occurred as a result of massive aspiration. These results indicate that everted cervical vein is comparable to the saphenous vein in resistance to bursting and can yield similar results as patch material after carotid endarterectomy. Accordingly, saphenous vein can be spared and lower extremity incisions avoided.(ABSTRACT TRUNCATED AT 250 WORDS)     

Saphenous vein patch rupture after carotid endarterectomy.

From January 1983 to September 1990, 2731 carotid endarterectomies were performed at The Cleveland Clinic. Patch angioplasty with autogenous saphenous vein was used for arteriotomy closure during 1691 (62%) of these procedures and was associated with eight postoperative ruptures (0.5%) of the central portion of the patch in seven patients. This complication occurred in three men and in four women (mean age, 69 years), all of whom were hypertensive and all but one were smokers. Two patients (29%) had diabetes. In each case of patch rupture the vein had been harvested from the leg distal to the knee. Although the harvest site could not be determined retrospectively for every patient in this series, no patch ruptures were encountered among 370 procedures for which it could be documented that the saphenous veins had been obtained from the groin. All ruptures occurred within 5 days of the primary operations (including four during the first 24 hours) and were urgently corrected by primary closure of the original arteriotomy in two cases and by replacement of the ruptured patch in the remaining six. Two (29%) of the seven patients either died or sustained a permanent neurologic deficit. Central rupture of a saphenous vein patch is a rare but devastating complication after carotid endarterectomy. Since vein harvested from the lower leg or ankle may be marginally more likely to rupture than proximal vein from the thigh or groin, it should not be used indiscriminately for carotid patch angioplasty.     

Long-term follow-up for recurrent stenosis: A prospective randomized study of expanded polytetrafluoroethylene patch angioplasty versus primary closure after carotid endarterectomy

Purpose: To determine the effect of primary closure (PC) versus expanded polytetrafluoroethylene patch graft angioplasty (PGA) on the incidence of recurrent stenosis (>50% lumen diameter narrowing) after carotid endarterectomy (CEA), 87 patients undergoing 100 consecutive CEA were prospectively randomized into two groups.Methods: Forty-four patients underwent 51 PC, and 43 patients underwent 49 PGA. All patients were evaluated after operation by duplex scanning at 1.5, 12, 24, and 36 months. There were no significant differences in the demographic characteristics or operative indications for CEA between the two patient groups. Complete follow-up was achieved in 86% (75/87) of the patients during the 36-month surveillance period.Results: The perioperative permanent neurologic morbidity in the PC and PGA groups was noted to be 4% and 2%, respectively (PC = 2/51 vs PGA = 1/49, p = 0.58). Three additional reversible cerebral ischemic events occurred in the postoperative period (PC = 2/51 vs PGA = 1/49, p = 0.58). Other morbidity included immediate postoperative hemorrhage requiring reexploration (1/51) in the PC group and an infected expanded polytetrafluoroethylene patch requiring removal and replacement with autogenous vein (1/49). Long-term follow-up detected a single patient with significant bilateral restenoses of his primarily closed carotid arteries. None of the patients in the PGA group had restenoses (PC = 2/51 vs 0/49, p = 0.50). In addition, no postoperative dilation of the common or internal carotid arteries or perioperative death was observed.Conclusions: In patients undergoing CEA, these data demonstrate no significant difference in the perioperative morbidity or mortality between PC and PGA. Use of the patch did not engender patients to patch rupture or aneurysmal degeneration as previously described with vein patch angioplasty procedures. This series supports effective use of either technique to achieve minimal rates of restenosis. (J VASC SURG 1994;19:198-205.)     

Carotid endarterectomy with bovine patch angioplasty: a preliminary report

Carotid endarterectomy with patch angioplasty is a durable procedure for prevention of recurrent neurological symptoms and stroke. However, no definitive study has demonstrated a clear benefit of one class of the patch material over another. The aim of this study was to evaluate the clinical outcome of carotid endarterectomy with bovine pericardium patch in comparison with autologous vein patch. One hundred and twenty-two carotid endarterectomies were performed using patch closure of the arteriotomy with bovine pericardium (61 cases) and autologous vein (61 cases) between September 1995 and June 1999. Though this is not a double-blind type randomized comparative study, effort was made to achieve a 1:1 ratio in sequence with a few exceptions such as non-available veins at time of surgery or for future use. In bovine pericardium patch closure group, the mean total operating time was significantly shorter than autologous vein closure group (P<0.01), but the mean carotid clamping time was similar in both groups, regardless of the use of shunt. The incidence of postoperative local complications including groin wound was less in bovine pericardium patch closure group. The patients were followed with duplex scans in one month post-CEA and 6 months interval thereafter. During the follow-up period, three patients developed non-critical stenosis (two in bovine and one in vein patch), and one aneurysmal dilation occurred in vein patch group. The incidence of restenosis was similar in both groups. Although this is a preliminary report, it is concluded that the results of carotid angioplasty using bovine pericardium compare favorably with autologous vein.     

Does routine patch angioplasty after carotid endarterectomy lessen the risk of perioperative stroke?

From 1964 through 1991 we performed primary closure of the arteriotomy in 1173 patients and patch angioplasty in 506 patients after carotid endarterectomy. The decision to patch was made at the surgeon's discretion. In general a patch was used for small arteries. In the primary closure group 32 patients (2.7%) had a perioperative stroke and in the patch angioplasty group 17 (3.4%) had a stroke. The difference (2.7% vs. 3.4%) was not significant (p<0.5275, Fisher's exact two-tailed test). A total of 240 arteries were closed with a vein patch and 11 (4.6%) of these patients had a stroke; 266 were closed with a synthetic patch (Dacron, 211; polytetrafluoroethylene, 55) and six of the patients had a stroke (2.3%). The difference in stroke rate between the vein and synthetic patch groups (4.6% vs. 2.3%) was not significant (p<0.2159). Patch angioplasty cannot be shown to reduce the incidence of perioperative stroke. Late carotid patency was not studied. This study supports a policy of selective patch angioplasty based on arterial size rather than patching all carotid arteries. When a patch is used, we prefer filamentous Dacron as the patch material.Presented at the Eleventh Annual Meeting of the Southern California Vascular Surgical Society, Dana Point, Calif., September 18–20, 1992.     

The Role of Polyester Patch Angioplasty in Carotid Endarterectomy: A Multicenter Study

The objectives of this study were to examine the morphology, restenosis, dilatation, and possible complications of polyester collagen impregnated carotid patches. Between March 1994 and January 1995, 207 patients (56 females and 151 males) undergoing 221 carotid endarterectomies (CE) with a collagen-impregnated knitted polyester patch were enrolled in a European prospective multicenter study. Patches were used for arteries deemed to be smaller than usual by visual inspection. General anesthesia was used in 201 procedures (91%), and a shunt was used in 76 procedures (34.4%). One hundred fourteen CE (51.6%) were checked by a perioperative arteriography or angioscopy. The diameter of the internal carotid artery (ICA) and carotid bulb (CB) were measured by duplex scan both preoperatively and every 6 months during follow-up. The main end point was carotid occlusion or restenosis, defined as a stenosis of 50% or more according to NASCET criteria. Carotid polyester-impregnated patches appear to be reliable. The patch was easy to cut and suture, and hemostasis was obtained immediately. No rupture occurred. However, the higher restenosis rate in women may restrict the use of polyester patch to men.     

Use of the internal jugular vein for carotid patch angioplasty

The internal jugular vein is an excellent source of autogenous tissue for carotid artery reconstruction because of its availability in the operative incision, adequate size, and ability to be harvested without morbidity. For 153 of 453 consecutive carotid reconstructions, the durability of the internal jugular vein (n = 76) and the greater saphenous vein (n = 77) as a patch angioplasty was compared. Mean postoperative follow-up was 17 months (1 to 52 months). The vein-patched carotid-bifurcation was studied by means of duplex ultrasonography to assess patency, detect restenosis, and measure cross-sectional diameter during systole. No carotid bifurcation occluded after operation. No ruptures or aneurysmal dilatations of the vein patches were observed. The maximum diameter (mean +/- SD) of the carotid patch angioplasties constructed with internal jugular vein (9.4 +/- 1.9 mm) was similar to patches made with greater saphenous vein (9.6 +/- 1.7 mm). In 95 patients serial duplex examinations demonstrated maximum diameter changes of the vein-patched internal carotid artery ranging from an increase of 3.5 mm to a decrease of 3.0 mm. Asymptomatic restenosis (greater than 50% diameter reduction) was detected in 2/95 (2.1%) patients. Because of the premium placed on the saphenous vein for peripheral arterial reconstruction and coronary artery bypass grafting, the ipsilateral internal jugular vein should be used more frequently for carotid patch angioplasty.