A fifteen-year experience with carotid endarterectomy after a formal operative protocol requiring highly frequent patch angioplasty.

PURPOSE: The early and late outcomes of carotid endarterectomy (CEA) following a rigid protocol of patch angioplasty or occasionally interposition bypass grafting, when the arteriotomy required to obtain a complete internal carotid end point extended distal to the bulb segment, and primary closure, when it was limited to the bulb, were studied.

METHODS: From November 1983 to August 1998, 1360 consecutive primary CEAs were performed on 1133 patients (621 men, 512 women), with a mean age of 67 years. Of these patients, 3.8% (51) had primary closure, 66.4% (903) had greater saphenous vein patch angioplasty, 28.4% (386) had synthetic (359 Dacron, 27 polytetrafluoroethylene) patch angioplasty, and 1.4% (20) had vein interposition bypass grafting procedures. Indications were transient ischemic attack in 34.7% of patients (472), stroke in 16.6% of patients (226), nonlateralizing symptoms in 10.9% of patients (148), and asymptomatic stenosis 70% or greater in 37.8% of patients (514). The mean follow-up period was 4.6 years.

RESULTS: The 30-day mortality rate was 1.0% (13 patients; 11 cardiac-related deaths, 2 strokes). The 30-day stroke rate was 1.3% (18 patients; 13 ipsilateral strokes, 5 major, 8 minor). The combined 30-day stroke and death rate was 2.1%. Four of the strokes (1 death) were caused by the hyperperfusion syndrome. The 30-day ipsilateral major stroke or mortality rate was 1.2% (16 patients). The 30-day rate of ipsilateral major stroke or death from stroke was 0.4% (5 patients). There were two synthetic and one vein patch internal carotid occlusions in 30 days. Synthetic-patched CEAs were predicted by means of Cox proportional hazards analysis to have higher risk ratios than saphenous vein-patched CEAs for early and late stroke (1. 3; 95% CI, 1.7 to 1.0; P =.04), for 50% or greater restenosis (2.4; 95% CI, 3.4 to 1.6; P <.001), and for 70% or greater restenosis (2. 5; 95% CI, 3.6 to 1.7; P <.001). The cumulative mortality rate (Kaplan-Meier) was 13% at 5 years and 31% at 10 years. The cumulative stroke rate was 7% at 5 years and 14% at 10 years. The 50% or greater restenosis rate was higher in women than in men at 5 years (9% versus 5%; P =.02, Wilcoxon), but tended to equalize later. The 50% or greater restenosis rate was higher in synthetic-patched CEAs than in saphenous vein-patched CEAs (12% versus 1% at 1 year; 17% versus 3% at 4 years; and 24% versus 10% at 8 years; P <.001 by means of log-rank and Wilcoxon). Restenosis after 5 years was more frequently located in the distal common carotid artery (13 of 20 cases). Late reoperations were more frequent and occurred earlier in synthetic-patched CEAs (eight cases at a mean of 1.6 years) than vein-patched CEAs (14 cases at a mean of 6.9 years; P =.01). No strokes and one restenosis of 50% or greater occurred in the 51 primarily closed CEAs.

CONCLUSION: Patch angioplasty reconstruction of CEAs with arteriotomies that extend distal to the carotid bulb gives excellent early and long-term outcomes. Saphenous vein-patched CEAs are superior to synthetic patched CEAs for stroke and restenosis prevention. Primary closure is safe and durable when complete end points and arteriotomies are within the carotid bulb.