Redo carotid surgery: An analysis of materials and configurations used in carotid reoperations and their influence on perioperative stroke and subsequent recurrent stenosis

Objective: The ideal method of arterial reconstruction in operations for re current carotid disease after prior endarterectomy is unknown. The goal of this study was to review a series of carotid reoperations and to determine whether the surgical technique influenced the rate of perioperative stroke, late stroke, or secondary restenosis. Methods: A retrospective review was conducted of 82 carotid reoperations pe rformed on 74 patients at our institution. Results: The patient population included 39 men (52.7%) and 35 women (47.3% ), with a mean age of 67.5 years. The indications for redo surgery included transient ischemic attack or amaurosis fugax in 35.3% of the patients, str oke in 6.1%, and asymptomatic restenosis (>80%) in 58.5%. Patch angioplasty with or without redo endarterectomy was used in 47 cases (57.3%), with sap henous vein in 26 (31.7%), Dacron in 15 (18.3%), and polytetrafluoroethylen e in 6 (7.3%). Interposition grafting was used in 35 cases (42.7%), with sa phenous vein in 9 (11.0%), Dacron in 10 (12.2%), and polytetrafluoroethylen e in 16 (19.5%). The perioperative complications included three strokes (3. 7%). There was a trend toward increased perioperative neurologic complicati ons with interposition grafting when compared with patch angioplasty (8.6% vs 2.1%), although this did not reach statistical significance. Long-term c linical follow-up was obtained in ail cases with a mean duration of 35 mont hs, with follow-up duplex scanning performed in 89.2%. The late failures of redo surgery included four significant secondary restenoses and five total occlusions. There was a trend towards improved long-term results with inte rposition grafting as opposed to patch angioplasty. However, the cases in w hich reconstruction was performed vith a vein had a significantly higher ra te of late failures (stroke, secondary recurrent stenosis, or occlusion) th an those in which reconstruction was performed with any prosthetic material (26.7% vs 2.3%; P=.002 by Fisher exact test). Conclusion: The use of autologous material for redo carotid surgery in any configuration appears to significantly increase the rate of subsequent recu rrent stenosis or total occlusion of the operated artery The reason for thi s finding is unclear but may be related to both host and technical factors. Prosthetic material may be more durable in the long-term for redo carotid surgery. Interposition grafting for redo carotid surgery may increase the p erioperative neurologic complication rate to some degree; however, this was not statistically significant in this series. Interposition grafting may b e a more durable solution in longterm follow-up than redo endarterectomy an d patch angioplasty. A longer follow-up period will be needed to confirm th is conclusion.