Popliteal Artery Occlusion in a Sole Sciatic Arterial System Requiring Complex Repair

Abstract

Objective: The utility of completion imaging after carotid endarterectomy (CEA) has remained controversial. We present our experience performing routine completion arteriography and its effect on the outcomes of CEA performed at our institution.Methods: A retrospective review of our prospectively maintained institutional database was performed. All patients who had undergone isolated CEA from 1992 to 2019 were included. Completion arteriography was performed by inserting a butterfly needle into the common carotid artery with manual injection of contrast in two views.Results: A total of 1439 isolated CEAs with completion arteriography were performed on 1297 patients. CEA was performed for asymptomatic lesions in 1003 cases (70%). Patch closure was performed in 1130 CEAs (78.5%) and eversion endarterectomy in 309 (21.5%). No complications related to arteriography occurred. Arteriography had documented significant abnormalities in the internal carotid artery and prompted revision in 24 of 1439 cases (1.7%), including 20 unsatisfactory distal endpoints of the CEA (12 with residual stenosis, 7 intimal flaps, and 1 dissection), 3 cases of kinking or stenosis within the body of the patch, and 1 thrombus. Of the 20 distal endpoint lesions, stent deployment was used in 17 cases and patch revision in 3. The other four cases were treated by patch angioplasty (n ¼ 3) or thrombectomy (n ¼ 1). None of these 24 patients experienced a perioperative stroke. The overall 30-day stroke, death, and combined stroke/death rate for the 1439 cases in our series was 1.5% (n ¼ 22), 0.5% (n ¼ 7), and 1.9% (n ¼ 27), respectively. The combined stroke/death rate for asymptomatic lesions was 1.1% (11 of 1003) and for symptomatic lesions was 2.5% (11 of 436). Of the 22 patients who had experienced stroke in the entire series (all of whom had had normal findings on the completion arteriogram), 15 had experienced a nonhemorrhagic stroke ipsilateral to the CEA. Of these 15 patients, 14 were confirmed to have widely patent endarterectomy sites by computed tomography angiography (n ¼ 13) or immediate reexploration and repeat arteriography (n ¼ 1). The patient with an occluded site had undergone reexploration and thrombectomy; however, no technical problems were identified. The other seven strokes were hemorrhagic (four with reperfusion syndrome and one with surgical site bleeding) or contralateral to the CEA (n ¼ 2).Conclusions: Although we recognize that not all patients in our series who had undergone immediate intraoperative surgical revision because of abnormal completion arteriography findings could have experienced a perioperative stroke, performing this quick, simple, and safe study might have approximately halved our overall perioperative CEA stroke rate from 3.2% to 1.5%.