A Technical Modification Of A Technical Modification Of Carotid Carotid EndEndarterectomy - arterectomy -

Experience With 400 PatientsExperience With 400 Patients

Faik Fevzi Okur Faik Fevzi Okur Sifa University Cardiovascular Surgery Dept.Sifa University Cardiovascular Surgery Dept.

Izmir / TURKEYIzmir / TURKEY

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Surgical Technique 1Surgical Technique 1

Neurosurg Focus. Neurosurg Focus. 2008;24(2):E182008;24(2):E18.. Links Links

Techniques in carotid artery surgeryTechniques in carotid artery surgery.. Curtis JA, , Johansen K.. Swedish Neuroscience Institute and Swedish Medical Center, Cherry Hill Swedish Neuroscience Institute and Swedish Medical Center, Cherry Hill

Campus Seattle, Washington, USA. curtis_ja@yahoo.com.auCampus Seattle, Washington, USA. curtis_ja@yahoo.com.au The major objective in carotid endarterectomy The major objective in carotid endarterectomy

is to achieve safe and complete removal of is to achieve safe and complete removal of intimal plaque and provide lasting, intimal plaque and provide lasting, nonstenotic closurenonstenotic closure. Controversy exists as to which technical . Controversy exists as to which technical variation best achieves this. In this paper, the authors review the operative variation best achieves this. In this paper, the authors review the operative nuances and outcomes with conventional and eversion endarterectomynuances and outcomes with conventional and eversion endarterectomy, , with a with a focus on the latter. The views expressed reflect specific neurosurgical and vascular perspectives in 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 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 open and endovascular means. The neurosurgical approach was almost entirely conventional endarterectomy with primary repair, while the vascular surgeons used the eversion method with few endarterectomy with primary repair, while the vascular surgeons used the eversion method with few exceptions.exceptions.

PMID: 18275295 [PubMed - in process]PMID: 18275295 [PubMed - in process]

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Surgical Technique 2Surgical Technique 2

J Vasc Surg. 2001 Sep;34(3):453-8.J Vasc Surg. 2001 Sep;34(3):453-8. Links Links

Durability of eversion carotid endarterectomy: Durability of eversion carotid endarterectomy: comparison with primary closure and carotid comparison with primary closure and carotid patch angioplastypatch angioplasty..

Katras T, , Baltazar U, , Rush DS, , Sutterfield WC, , Harvill LM, , Stanton PE Jr.. Department of Surgery, Division of Vascular Surgery, James H. Quillen College of Medicine, East Tennessee State University, Johnson City Department of Surgery, Division of Vascular Surgery, James H. Quillen College of Medicine, East Tennessee State University, Johnson City

37604, USA. katras@etsu.edu37604, USA. katras@etsu.edu OBJECTIVES: Despite numerous studies in which various methods for arteriotomy closure after carotid endarterectomy (CEA) have been OBJECTIVES: 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 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 technique with those of conventional CEA with either primary 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 and restenosis 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 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 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 (not significant [NS]). The choice of CEA technique was not 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 were excluded or 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. 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 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 eversion CEA was 0.8% (1 patient), for CEA-primary closure it was 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% after eversion CEA, 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 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-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). Transient ischemic attacks occurred in 2.5% after eversion CEA, in 5.2% 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 all three groups was 23 months 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 (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 angioplasty (P <.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 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 to operative morbidity and mortalitybetween eversion CEA and these more widely accepted CEA closure techniques with respect to operative morbidity and mortality . . These data indicate, however, that eversion CEA has a These data indicate, however, that eversion CEA has a lower restenosis rate than conventional CEA closure lower restenosis rate than conventional CEA closure techniques and thus superior long-term durabitechniques and thus superior long-term durabilitylity..

PMID: 11533597 [PubMed - indexed for MEDLINE]PMID: 11533597 [PubMed - indexed for MEDLINE]

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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 Primary closure of the carotid artery is associated with

poorer outcomes during carotid endarterectomy.poorer outcomes during carotid endarterectomy. Rockman CBRockman CB, , Halm EA, , Wang JJ, , Chassin 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 INTRODUCTION: Arterial endarterectomy and reconstruction during carotid endarterectomy (CEA) can be performed in a variety

of ways, of ways, including standard endarterectomy with primary closure, standard endarterectomy with patch angioplasty, and eversion including standard endarterectomy with primary closure, standard endarterectomy with patch angioplasty, and eversion endarterectomyendarterectomy. The optimal method of arterial reconstruction remains a matter of controversy. The objective of this study was to . 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 perioperative outcome. METHODS: A retrospective 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. 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 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 inpatient chart, outpatient surgeon record, and the hospitals' administrative databases. Two physician independent review of the inpatient chart, 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 investigators--one neurologist and one internist--confirmed each adverse event by independently reviewing patients' medical records.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 . 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% 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 of arterial reconstruction was chosen by the surgeon. Primary closure 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 eversion endarterectomy in 18.4% (n = 362). There 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 compared with the 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 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 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 death compared with the other closure techniques (6.0% vs 2.5%, P = .006). 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, or perioperative stroke/death noted when 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% (P = 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 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 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 advocates have reported that they can properly select appropriate 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 these patients have patients for primary closure based on the size of the artery and other factors, the data demonstrate that these patients have

poorer outcomes nonetheless. poorer outcomes nonetheless. Primary closure during carotid endarterectomy Primary closure during carotid endarterectomy should predominantly be abandoned in favor of either standard should predominantly be abandoned in favor of either standard endarterectomy with patch angioplasty or eversion endarterectomy with patch angioplasty or eversion endarterectomy.endarterectomy.

Surgical Technique 3Surgical Technique 3

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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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9

10

11

12

13

14

15

16

17

18

19

20

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Left CEA post op 42. month.Left CEA post op 42. month.

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Left CEA post op 36. month.Left CEA post op 36. month.

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Left CEA post op 36. month. Left CEA post op 36. month.

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Right CEA post op. 36. Month.Right CEA post op. 36. Month.

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