A meta-analysis of randomized trials comparing bovine pericardium and other patch materials for carotid endarterectomy.

OBJECTIVE: Patch angioplasty during carotid endarterectomy is commonly used to treat symptomatic and asymptomatic carotid artery stenosis. The objective of the present study was to compare the different patch materials that are currently available (synthetic vs venous vs bovine pericardium) in terms of short- and long-term outcomes.

METHODS: This study was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and eligible randomized control trials were identified through a comprehensive search of PubMed, Scopus, and Cochrane Central published until September 2017. A meta-analysis was conducted with the use of a random effects model. The I2 statistic was used to assess for heterogeneity. The primary study end point was the incidence of long-term restenosis. Secondary study end points were 30-day stroke, transient ischemic attack (TIA), myocardial infarction, neck wound infection, local hematoma, carotid artery thrombosis, cranial nerve injury, long-term stroke incidence, and death.

RESULTS: Eighteen studies and 3234 patients were included. The risk of 30-day stroke (relative risk [RR], 1.00; 95% confidence interval [CI], 0.45-2.19; I2  = 0%), TIA (RR, 1.14; 95% CI, 0.41-3.19; I2  = 0%), myocardial infarction (odds ratio, 0.75; 95% CI, 0.14-3.97; I2  = 0%), death (RR, 0.53; 95% CI, 0.21-1.34; I2  = 0%), wound infection (RR, 1.84; 95% CI, 0.43-7.81; I2  = 0%), carotid artery thrombosis (RR, 1.47; 95% CI, 0.44-4.97; I2  = 0%), cranial nerve palsy (RR, 1.21; 95% CI, 0.53-2.77; I2  = 0%), and long-term stroke (RR, 2.33; 95% CI, 0.76-7.10; I2  = 0%), death (RR, 1.09; 95% CI, 0.65-1.83; I2  = 0%) and restenosis of greater than 50% (RR, 0.48; 95% CI, 0.19-1.20; I2  = 0%) were similar between the synthetic vs venous patch groups. Also, no differences in terms of 30-day stroke (RR, 0.31; 95% CI, 0.02-5.16; I2  = 63.1%), TIA (RR, 0.49; 95% CI, 0.14-1.76; I2  = 0%), death (RR, 0.74; 95% CI, 0.05-10.51; I2  = 31.7%), carotid artery thrombosis (RR, 0.13; 95% CI, 0.02-1.07; I2  = 0%), and long-term restenosis of greater than 70% (RR, 0.15; 95% CI, 0.01-2.29; I2  = 70.9%) were detected between the synthetic polytetrafluoroethylene and Dacron patch groups. The comparison between the bovine pericardium vs synthetic patch did not yield any statistically significant results in terms of 30-day stroke (RR, 1.44; 95% CI, 0.19-10.79; I2  = 12.7%), TIA (RR, 1.05; 95% CI, 0.11-10.27; I2  = 0%), local neck hematoma (RR, 4.01; 95% CI, 0.46-34.85; I2  = 0%), and death (RR, 4.01; 95% CI, 0.46-34.85; I2  = 0%).

CONCLUSIONS: Closure of the carotid arteriotomy with any of the studied patch materials seems to be similar in terms of short- and long-term end points. However, additional randomized trials with adequate follow-up periods are needed to compare bovine pericardium patches with other patch materials.