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.)     

Bovine pericardial patch angioplasty in carotid endarterectomy

Patch angioplasty during carotid endarterectomy (CEA) has been shown to reduce the incidence of both early and late complications. Controversy continues, however, over the ideal patch material. Bovine pericardium (Vascu-Guard Biovascular Inc., Saint Paul, MN) offers an attractive alternative to other patch materials because of its handling and suturing characteristics that are similar to that of autogenous material. This study examines the perioperative and midterm results of bovine pericardial patch angioplasty during CEA. We studied 112 patients who underwent 129 CEAs with bovine pericardial patch angioplasty during an 18-month period. Data were collected regarding demographics, operative indications, perioperative complications, and the occurrence of late adverse outcomes based primarily on follow-up arterial duplex studies. Among this group there were 63 male (56%) and 49 female (44%) patients whose mean age was 71.8 +/- 9.1 years. In these patients there was the typical distribution of atherosclerotic risk factors. Seventy-four patients (66%) had symptomatic disease preoperatively and the remaining 38 patients (34%) were asymptomatic. Temporary cranial nerve palsy occurred in three patients (2%). There were no perioperative strokes, acute occlusions, bleeding episodes requiring reoperation, or deaths. The patients were followed up to 54 months postoperatively with a mean follow-up time of 41.7 +/- 4.4 months. During this period two patients (2%) developed three significant restenoses (70-99%). All required reoperation. There were no asymptomatic occlusions, infections, aneurysms, or rupture. These data demonstrate that bovine pericardial patch angioplasty during CEA is associated with a low incidence of both perioperative and midterm adverse outcomes.     

EEG monitoring during carotid endarterectomy

One hundred and thirty-one patients undergoing 142 carotid endarterectomy procedures were randomized to have their operation performed either with or without intra-operative electroencephalographic (EEG) monitoring. Patients with EEG monitoring were shunted if both the internal carotid back pressure (ICBP) was less than 50 mmHg and ipsilateral change was evident on the EEG after clamping. Patients without EEG monitoring were shunted if ICBP was less than 50 mmHg. There one postoperative death (0.7%) with neurological deficits occurring in five patients (3.5%). There were significantly fewer neurological deficits (P = 0.02) in patients with no EEG change (one of 59) compared with those with EEG change (two of 13). There was a highly significant increase (P = 0.005) in incidence of neurological deficit (two of five patients) when ICBP was considered 'adequate' at 50 mmHg or greater but EEG change occurred. No neurological deficit occurred in 14 patients who were not shunted with ICBP less than 50 mmHg but with no EEG change. There was no difference in the incidence of neurological deficit in patients with low and high ICBP when both 50 and 55 mmHg were used as the cut-off points. It is concluded that EEG monitoring is useful in identifying patients requiring shunting during carotid endarterectomy. Use of a shunt is recommended if there is EEG change regardless of ICBP; conversely, if ICBP is low but there is no EEG change it would appear safe to proceed without shunting.     

Technique and clinical results of carotid stump back-pressure to determine selective shunting during carotid endarterectomy

A method of confirming carotid back pressure accuracy, variability during carotid clamping, and the clinical results with a modified back pressure shunt criterion were evaluated in 665 carotid endarterectomies. Mean arterial pressure, back pressure, and internal jugular vein pressure were measured. Cerebral perfusion pressure (back pressure-jugular vein pressure) and the collateral to hemisphere vascular resistance ratio, (ratio = [arterial pressure-back pressure]/[back pressure-jugular vein pressure]) were calculated. A shunt was used when cerebral perfusion pressure less than 18 mm Hg. Back pressure accuracy was confirmed by test occlusion of the internal carotid artery distal to the plaque. Initial back pressure values were falsely high in 83 (12.5%) carotid endarterectomies. The mean SD (n = 665, mm Hg) were arterial pressure = 84.0 +/- 9.06, back pressure = 41.0 +/- 15.9, jugular vein pressure = 6.2 +/- 3.9, cerebral perfusion pressure = 35.1 +/- 5.7, and resistance ratio = 1.85 +/- 1.44. Perfusion pressure was less than 18 mm Hg in 82 (12.3%), of which 74 (11.1%) were shunted, and 8 (1.2%) had perfusion pressure increased greater than or equal to 18 mm Hg during carotid endarterectomy with phenylephrine. Back pressure was less than 25 mm Hg in 107 (16.1%), less than or equal to 25 in 114 (17.1%), and less than 50 mm Hg in 481 (72.3%). Pressures were continuously monitored during 28 carotid endarterectomies, and all had a positive linear relationship between arterial pressure and back pressure, and minimal variability in the back pressure/arterial pressure and resistance ratios. Only two patients (0.3%) had a new neurologic deficit in the first 12 hours after carotid endarterectomy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Results of routine shunting and patch closure during carotid endarterectomy

BackgroundThe role of shunting and patching during carotid endarterectomy remains controversial.MethodsThis is a retrospective case series evaluating consecutive patients undergoing carotid endarterectomy with routine shunting and patching. The primary endpoints were perioperative stroke, arterial injury, and lesion recurrence by duplex.ResultsOf the 220 operations performed, 43% were for symptomatic disease. Successful shunt placement occurred in 98%, with no shunt-related injuries. There was 1 minor perioperative stroke and no major strokes. At a mean follow-up of 24 months (median = 12 months), there was 1 restenosis potentially related to shunt placement. The incidence of asymptomatic >50% stenosis in the patched segment was 8%.ConclusionsA combined policy of routine shunting and patching simplifies intraoperative decision making with results that rival or exceed those of trials in which their use was not standardized. Shunts need not be avoided because of concern of arterial injury.     

Computerised EEG monitoring for carotid endarterectomy

A prospective study was undertaken in twenty patients undergoing carotid endarterectomy using computerised EEG monitoring in the form of a density-modulated spectral array, spectral edge frequency and integrated EEG power for monitoring cerebral ischaemia. This form of monitoring proved to be easy to use and understand. Because ischaemic EEG events longer than one minute were not necessarily followed by postoperative deficits, the definition of significant events that would cause ischaemia may need to be modified.     

Carotid endarterectomy outcome with vein or Dacron graft patch angioplasty and internal carotid artery shortening

OBJECTIVE: This analysis of the outcome of carotid endarterectomy (CEA) was performed during a period of transition from the frequent use of autologous greater saphenous vein grafting to the frequent use of Dacron graft patch reconstruction and from the infrequent use to the moderate use of eversion plication shortening of the endarterectomized internal carotid artery segment. METHODS: From 1990 to 1997, 697 consecutive primary CEAs were performed on 326 men (61 bilateral CEAs) and 272 women (38 bilateral CEAs) with a mean age (+/- SD) of 68 +/- 9 years. The indications were transient ischemic attack in 31% of the patients, stroke or reversible ischemic neurologic deficit in 18%, global ischemia in 12%, and asymptomatic stenosis >/=70% in 39%. Patch reconstruction was performed in the 678 CEAs in which the arteriotomy extended distal to the internal carotid artery bulb (97%; 370 saphenous vein grafts, 308 Dacron grafts). Primary closure was used in the other 19 CEAs. Early in this series, saphenous vein patching frequently was performed, with a gradual transition to the frequent use of knitted Dacron grafts. Concurrent with this, the frequency of the shortening of the internal carotid artery increased from 7% to 40%. Postoperative duplex scans were obtained on 619 CEAs (91%). RESULTS: There were four deaths (0.6%) in 30 days-three from myocardial infarction and one from hyperperfusion stroke. Thirteen strokes (1.9%), nine ipsilateral and four contralateral, occurred in 30 days. Four nonfatal strokes and one death occurred in the saphenous vein group (3.2%), and eight strokes and two deaths occurred in the Dacron graft group (1.4%; P =.16). The combined 30-day stroke or death rate was 2.3% (16/697), and the hospital rate was 1.7% (12/697). Of the three internal carotid artery occlusions, two were identified at 2 months (one Dacron graft, one saphenous vein) and one was identified at 1 year (Dacron graft). Nonocclusive (>/=50%) restenosis was identified in 16 CEAs. Fifteen of these were in the internal carotid artery. The cumulative Kaplan-Meier method of life-table analysis for the >/=50% restenosis rate at 2 months, 6 months, 1 year, and 3 years for Dacron graft patched CEA was 1.7%, 2.3%, 8.8%, and 12.3% and for saphenous vein patched CEA was 0.3%, 0.3%, 0.3%, and 1.1% ( P <.0001). At the same time intervals, the >/=50% restenosis rate for internal carotid artery shortening was 1.0%, 2.5%, 13.7%, and 19.5%, and, when shortening was not done, the rate was 0.8%, 0.8%, 1.1%, and 3.1% (P <.0001). The >/=50% restenosis rate at the same intervals for women was 0.8%, 1.3%, 5.2%, and 8.9%, and, for men, the rate was 0.9%, 0.9%, 1.8%, and 2.5% (P =.11). Univariate analysis of the rate of >/=50% restenosis in 3 years for the 346 vein patched (2; 0.6%) and 186 Dacron graft patched (7; 3.8%) CEAs that did not have internal carotid artery shortening gave a P value of .015. Similarly, Kaplan-Meier method analysis of this subset of nonshortened CEAs gave a higher restenosis rate with Dacron graft patching (P =.012). With multiple logistic regression, the >/=50% restenosis rate was significantly associated with Dacron graft patching (P =.023; odds ratio, 4.5) and internal carotid artery shortening (P =.025; odds ratio, 3.1) and was weakly associated with female gender (P =.15; odds ratio, 2.0). Cox proportional hazards model analysis for >/=50% restenosis gave relative risk ratios of 3.0 (1.6 to 6.8; 95% confidence interval [CI]) for Dacron graft versus vein patching, 2.0 (1.2 to 3.3; 95% CI) for shortening versus not shortening, and 1.5 (0.9 to 2.4; 95% CI) for female versus male gender. CONCLUSION: CEA patching with Dacron grafts and saphenous vein grafts have similar low perioperative thrombosis, stroke, and death rates, although the stroke and death rates were slightly higher but not statistically different when Dacron grafts were used. Dacron graft patched CEAs are more likely to develop >/=50% restenosis than are those that are patched     

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.     

Late follow-up of carotid endarterectomy with venous patch angioplasty

Ninety carotid endarterectomies with venous patch angioplasty were performed in 83 patients between July 1980 and December 1985. The primary indication for patching was a small-caliber internal carotid artery (ICA) with a diameter less than 3.0 mm in 54 arteriotomies (60%). Patency of the endarterectomy was evaluated by completion arteriography in all instances. Follow-up was conducted after an intermediate postoperative period of 21 +/- 12.5 months in 69 sides by arteriography. A late follow-up was conducted at 55.4 +/- 11.2 months either by arteriography (in 45 sides) or by carotid duplex scanning (in 11 sides). Twenty-one patients with 23 endarterectomies died, only 1 of a cerebral event. Seven patients moved or refused study and five were lost to follow-up. Three recurrent stenoses and five carotid occlusions developed by the time of the intermediate follow-up. By the time of late follow-up, three additional patients developed recurrent stenoses. Our results suggest that recurrent stenosis continues to develop with a longer period of follow-up in patients undergoing venous patch angioplasty with carotid endarterectomy.     

Nine-year experience of bovine pericardium patch angioplasty during carotid endarterectomy

PURPOSE: This paper examines the clinical results of a 9-year experience in which the incidence of major (stroke and death) perioperative events and of recurrent stenosis (>60%) after carotid endarterectomy performed with a direct suture (DS) of the arteriotomy versus bovine pericardium patch angioplasty (BPPA) are compared. Methods and Materials: A total of 517 carotid endarterectomies were included in this nonrandomized study and were divided into two groups: group DS with 194 procedures and group BPPA with 323 procedures. All patients were entered in a follow-up program that ranged from 1 to 108 months (mean, 56.4 months) and included color duplex scan examinations at 1, 3, 6, and 12 months after surgery and every year thereafter. RESULTS: The number of major (stroke and death) perioperative cerebrovascular accidents was eight (4.1%) in the DS Group and five (1.5%) in the BPPA group (P =.066). One death occurred in the DS group, and three occurred in the BPPA Group (P =.517). The four deaths in both groups were the result of strokes. No statistically significant difference was found in terms of early neurologic complications between the two groups. During the first year of follow-up study, the rate of restenosis >60% and occlusion was significantly lower in the BPPA group. Thereafter, the difference was not significant. CONCLUSION: In our experience, the use of BPPA or DS during carotid endarterectomy procedure does not cause a significantly different rate of perioperative major events (stroke or death) in the two groups. The incidence rate of restenosis is lower in the first year after surgery with BPPA, but in subsequent years, no significant difference in restenosis is seen. The early and late postoperative results with BPPA compare favorably with the reported data from literature with the use of other patch materials.     

Infected false aneurysm following carotid endarterectomy with vein patch angioplasty

The authors report a case of infected false aneurysm that developed after carotid endarterectomy with vein patch angioplasty. This complication is extremely rare and occurs most commonly when a Dacron patch graft has been employed. Various clinical presentations are described and the etiology of infection is discussed. Surgical management consisted of the resection of the pseudoaneurysm and segmental replacement with vein. Parenteral antibiotic therapy was given for three weeks and topical irrigation with an antiseptic solution performed for two weeks.     

Postoperative infection associated with polyester patch angioplasty after carotid endarterectomy

OBJECTIVES: Postoperative infection is one of the most dreaded complications associated with use of synthetic patches for carotid endarterectomy. Although polyester patches were used extensively for carotid patch angioplasty throughout the last decade, few reports detail cases of deep patch infection. We describe our experience with polyester patch infections after carotid endarterectomy.Patients and methods From January 1996 through December 2001 we treated polyester patch infections after carotid endarterectomy in 10 patients. RESULTS: The interval from primary carotid endarterectomy to presentation with infection ranged from 11 days to 30 months. All patients underwent repeat operation that involved tissue debridement, excision of the polyester patch, and either interposition grafting or patch angioplasty with autologous vein. No perioperative stroke or death occurred; however, 1 patient had transient hoarseness, and in 1 patient a pseudoaneurysm developed that required additional surgical repair with a saphenous vein interposition graft. All patients remain well and free of infection with follow-up as long as 56 months. CONCLUSIONS: Infection is a serious and rare complication of carotid patch angioplasty with polyester material. Nonetheless, it can be treated successfully with good results and acceptable morbidity with soft tissue debridement, prosthetic patch excision, and either patch angioplasty or interposition grafting with autologous vein.     

Routine electroencephalographic (EEG) monitoring during carotid endarterectomy.

Controversy continues concerning the advisability of routine shunting, no shunting, or selective shunting during carotid endarterectomy. Because of its reflection of the physiologic state of the end organ, the authors chose routine 18 lead EEG monitoring as a guide to selective shunting and as an indication of adequate shunt function during all carotid endarterectomies performed from December 1977 through July 1982. In that period, 200 patients underwent 219 endarterectomies under general anesthesia and EEG monitoring. Ischemic EEG changes at the time of carotid cross clamping suggested the need for intraluminal shunts in 16% of patients. Insertion of shunts restored the EEG pattern to normal in all instances, although in two patients, adjustment of the shunt was required to maintain this results. EEG changes requiring shunting occurred in 10% of patients with unilateral disease, in 27% of patients with bilateral disease, and in 42% of patients with unilateral stenosis and contralateral occlusion. Twenty-seven patients had small fixed neurologic deficits before operation. Surgery was not delayed in these individuals who demonstrated no increased requirement for shunts and no new postoperative neurologic deficits. In the group of 150 endarterectomies performed as separate procedures, there was one (0.7%) fixed neurologic deficit after operation, one transient deficit (0.7%), and one death (0.7%). Sixty-nine endarterectomies were performed simultaneously with open heart surgery and were associated with one fixed neurologic deficit (1.4%) and two transient deficits (2.9%). All four deaths in this group were attributable to the cardiac surgical procedures. These results indicate that selective shunting based on EEG monitoring permits the safe performance of carotid endarterectomy, even in patients considered to be at high risk for postoperative neurologic deficit.     

Cerebral oximetry monitoring during carotid endarterectomy: effect of carotid clamping and shunting

Cerebral oximetry is a simple method of measuring regional cerebral oxygen saturation (rSO(2)). One promising application is its use during carotid endarterectomy (CEA) to help minimize the risk of perioperative stroke. The authors used the INVOS-4100 cerebral oximeter at several steps during CEA to measure the effect of carotid clamping and shunting on rSO(2). The authors prospectively evaluated 42 consecutive CEAs in 40 patients. All had CEA under general anesthesia with the routine use of a Javid shunt. The INVOS-4100 oximeter was used to measure rSO(2) before clamping (t1), after clamping but before shunting (t2), 5 minutes after shunt insertion (t3), and after patch closure with reestablished flow (t4). The Wilcoxon signed-rank and rank-sum tests were used for analysis. Clamping of the internal carotid artery (t1 vs t2) resulted in a drop of ipsilateral rSO(2) by -12.3% (p < 0.001). Shunt insertion (t2 vs t3) increased rSO(2) by 10.9% (p < 0.001). Contralateral rSO(2) for the same time periods was insignificant. Patients with preoperative neurologic symptoms had a greater decrease in rSO(2) after clamping (-18.4%) compared with a decrease of -10.4% in asymptomatic patients (p = 0.037). Cerebral oximetry monitoring is simple and inexpensive. The study showed statistically significant changes in rSO(2) as a result of clamping and shunting of the carotid artery. Symptomatic patients had a greater drop in rSO(2).     

External carotid endarterectomy with patch angioplasty using internal jugular vein--two case reports.

A 59-year-old male and a 74-year-old male presented with occlusion of the right internal carotid artery and stenosis at the origin of the ipsilateral external carotid artery manifesting as cerebral ischemia. External carotid endarterectomy with patch angioplasty using the internal jugular vein was performed. Special care was taken to obliterate the stump of the carotid artery using a Weck clip in one case and plication with non-absorbable sutures in the other. Cerebral blood flow in the affected hemisphere was increased after surgery and the patients remained asymptomatic. External carotid endarterectomy has several special aspects such as patch angioplasty and elimination of the stump which must be understood.     

A prospective study of vein patch angioplasty during carotid endarterectomy. Three-year results for 801 patients and 917 operations.

From 1983 through 1985, 801 consecutive patients (mean age: 66 years) underwent 917 primary carotid endarterectomies at the Cleveland Clinic. Conventional arteriotomy closure was performed during 483 operations, while patch angioplasty using a distal segment of saphenous vein was employed in 434. Preoperative risk factors, surgical management, and antiplatelet therapy were equivalent in the vein patch (VP) and nonpatch (NP) groups. Early results were evaluated by intravenous angiography (DSA) in 715 patients (89%), and 332 reconstructions (36%) have been reassessed by objective imaging during a mean follow-up interval of 21 months. Ischemic strokes occurred after 18 (1.9%) of the 917 procedures (0.7% VP, 3.1% NP; p = 0.0084), and symptomatic (N = 9) or unsuspected (N = 8) thrombosis of the internal carotid artery was confirmed by neck exploration or routine DSA after 1.9% of all operations (0.5% VP, 3.1% NP; p = 0.0027). Only ten patients (1.2%) have required reoperations for severe recurrent lesions, but the cumulative 3-year incidence of new defects (greater than or equal to 30% stenosis) documented by objective studies in the VP and NP groups was 9% and 31%, respectively (p = 0.0066). These results strongly suggest that VP angioplasty enhances the safety and durability of carotid endarterectomy.