A comparison of results with eversion versus conventional carotid endarterectomy from the Vascular Quality Initiative and the Mid-America Vascular Study Group

Abstract

Objective Carotid endarterectomy (CEA) is usually performed with eversion (ECEA) or conventional (CCEA) technique. Previous studies report conflicting results with respect to outcomes for ECEA and CCEA. We compared patient characteristics and outcomes for ECEA and CCEA. Methods Deidentified data for CEA patients were obtained from the Society for Vascular Surgery Vascular Quality Initiative (SVS VQI) database for years 2003 to 2013. Second (contralateral) CEA, reoperative CEA, CEA after previous carotid stenting, or CEA concurrent with cardiac surgery were excluded, leaving 2365 ECEA and 17,155 CCEA for comparison. Univariate analysis compared patients, procedures, and outcomes. Survival analysis was also performed for mortality. Multivariate analysis was used selectively to examine the possible independent predictive value of variables on outcomes. Results Groups were similar with respect to sex, demographics, comorbidities, and preoperative neurologic symptoms, except that ECEA patients tended to be older (71.3 vs 69.8 years; P < .001). CCEA was more often performed with general anesthesia (92% vs 80%; P < .001) and with a shunt (59% vs 24%; P < .001). Immediate perioperative ipsilateral neurologic events (ECEA, 1.3% vs CCEA, 1.2%; P = .86) and any ipsilateral stroke (ECEA, 0.8% vs CCEA, 0.9%; P = .84) were uncommon in both groups. ECEA tended to take less time (median 99 vs 114 minutes; P < .001). However, ECEA more often required a return to the operating room for bleeding (1.4% vs 0.8%; P = .002), a difference that logistic regression analysis showed was only partly explained by differential use of protamine. Life-table estimated 1-year freedom from any cortical neurologic event was similar (96.7% vs 96.7%). Estimated survival was similar comparing ECEA with CCEA at 1 year (96.7% vs 95.9%); however, estimated survival tended to decline more rapidly in ECEA patients after ~2 years. Cox proportional hazards modeling confirmed that independent predictors of mortality included age, coronary artery disease, chronic obstructive pulmonary disease, and smoking, but also demonstrated that CEA type was not an independent predictor of mortality. The 1-year freedom from recurrent stenosis >50% was lower for ECEA (88.8% vs 94.3%, P < .001). However, ECEA and CCEA both had a very high rate of freedom from reoperation at 1 year (99.5% vs 99.6%; P = .67). Conclusions ECEA and CCEA appear to provide similar freedom from neurologic morbidity, death, and reintervention. ECEA was associated with significantly shorter procedure times. Furthermore, ECEA obviates the expenses, including increased operative time, associated with use of a patch in CCEA, and a shunt, more often used in CCEA in this database. These potential benefits may be reduced by a slightly greater requirement for early return to the operating room for bleeding.

Outcomes of mini-incision eversion carotid endarterectomy combined with nontouch isolation technique of the internal carotid artery

“…A multinational European registry reported an eversion CEA rate of 26%, 19 and the Vascular Quality Initiative and the Mid-America Vascular Study Group reported an eversion CEA rate of 12%. 20 Ballotta et al 21 reported excellent outcomes of eversion CEA, with perioperative stroke in 8 of 2007 procedures (0.39%). A systematic review that compared conventional and eversion CEA reported that the stroke rate in eversion CEA was 1.4%.…”

Carotid Body Baroreceptor Preservation and Control of Arterial Pressure in Eversion Carotid Endarterectomy

“…Other important benefits are the optimum correction of the ICA and reduction of surgical time, the possibility of aneurysm' s development by use of venous patch, the contamination after synthetic patch use, as well as the restenosis rate. 3,[8][9][10] The typical ECEA includes the oblique transection of the internal carotid to the carotid bifurcation, the removal of the atherosclerotic plaque by the inverse technique from the internal carotid and the region of the bifurcation or more caudally, and the reimplantation of the internal carotid into the central stump.…”

Carotid stenosis – basing treatment on individual patients’ needs. Optimal medical therapy alone or accompanied by stenting or endarterectomy

“…• Eversion CEA (plaque removal following transection of the distal internal carotid artery) and conventional longitudinal CEA (patch angioplasty or direct closure) proved to be similar in regard to freedom from neurologic morbidity, death, and reintervention. However, eversion CEA has a signifi cantly lower rate of late stenosis [64,65]. By meta-analysis, Demirel et al [66] found moderate evidence for an increased rate of post-CEA hypertension (OR 2.8) with eversion CEA.…”