Patch variability following carotid endarterectomy: a survey of Great Britain and Ireland

Abstract

INTRODUCTIONEvidence suggests a clinical benefit with patch angioplasty after carotid endarterectomy (CEA). The UK National Vascular Database has demonstrated variation in practice but does not record technical details. This study was intended to define indications and technique of patching after CEA.METHODSAn electronic questionnaire was emailed to all 402 members of the Vascular Society of Great Britain and Ireland. The email could not be received by 23 and 14 did not perform CEA. Some questions allowed multiple answers. Fisher’s exact test was used for statistical analysis.RESULTSThere were 187 responses (51%). Fifteen members (8%) performed eversion CEA, which obviates patching. Of all the respondents, 121 surgeons (65%) always use a patch. Seventy of these (58%) use the full patch width (median: 8mm, range: 4–10mm). Fourteen (12%) variably trimmed the patch (median: 7.5mm, range: 5–10mm) and 34 (28%) routinely trimmed (median: 6mm, range: 3–20mm). Selective patching, dependent on internal carotid artery diameter, was performed by 48 respondents (26%), 23 of whom specified a median artery threshold diameter of 5mm (range: 3–8mm). General anaesthesia was always or usually used by 83 surgeons (45%), local anaesthesia by 77 (41%) and the remainder followed patient choice. Obligatory patching is performed by 68 of the 83 respondents (82%) who prefer general anaesthesia whereas only 40 of the 77 surgeons (52%) who use local anaesthesia always patch (p<0.0001).CONCLUSIONSThere is a variable rate of patching after CEA in the UK, which appears dependent on the vessel size and mode of anaesthesia. There are also differences in the patch width adopted.

Computational fluid dynamic comparison between patch-based and primary closure techniques after carotid endarterectomy

“…30,31 Despite those recommendations, a survey of vascular surgeons reported that individual preferences on this issue still vary widely. 32 Hemodynamics is a determining factor in the growth of carotid atheromatous disease. Regions affected by low and oscillating WSS are associated with monocyte activation, increased vasoconstriction, oxidative stress, higher cellular turnover, and apoptosis.…”

Is primary closure still a reliable technique in carotid endarterectomy?

“…The general view is that the patch closure method minimizes the risk of perioperative and long-term stroke and restenosis, compared to the primary closure method; however, the existence of controversial results requires more studies to support these findings. [7,8,[16][17][18] There is still no consensus among the surgeons about the closure technique and, therefore, each surgeon decides on the closure technique based on his or her own experience. In the present study, we found no statistically significant difference in the perioperative results, except for hematoma, between the two groups.…”