A SYSTEMATIC REVIEW OF THE RANDOMIZED TRIALS OF CAROTID PATCH ANGIOPLASTY IN CAROTID ENDARTERECTOMY

Objectives: To determine whether patch angioplasty is move effective t han primary closure in carotid endarterectomy, and whether one type of patch is better than another. Design: Systematic review of the random ised trials. Materials: Trials were identified from the Cochrane Strok e Review Group database plus additional handsearching, electronic sear ching, and personal contact. Methods: Two authors independently select ed studies for inclusion and extracted details of trial quality and da ta on the following outcomes: any stroke; stroke ipsilateral to the op erated artery; death; occlusion or restenosis, and other significant a rterial complications. Meta-analysis of odds ratios (OR) was performed using the Peto method. Results: Six trials (882 operations) compared routine patching with primary closure. Routine patching pas associated with significant reductions in the visits of ipsilateral stroke durin g the perioperative period (OR 0.34, 95% CI 0.15-0.76) and during long -term follow-up (OR 0.38, 95% CI 0.16-0.88). Significant reductions in the odds of any stroke, stroke or death, acute arterial occlusion and long-term restenosis were also found. However, these results were bas ed on very small numbers of outcome events and may be biased by losses to follow-up and publication bias. Three trials (326 operations) comp ared the nse of polytetrafluoroethylene patches with venous patches. T here were too few events (strokes, deaths, arterial complications) to determine whether there were significant differences between the patch materials. Fewer pseudoaneurysms occurred in those who received synth etic patches but the clinical consequence of this was unclear. Conclus ions: Routine carotid patch angioplasty was associated with promising reductions in the risks of ipsilateral al stroke and death, but the re sults should be interpreted cautiously because of the small number of outcome events, significant losses to follow-up, and poor trial method ology. Ideally, a large definitive trial should be performed. There is insufficient evidence to support the preferential use of one particul ar type of patch versus another.