Randomized trial of vein versus Dacron patching during carotid endarterectomy: Influence of patch type on postoperative embolization

Purpose: A recent overview indicated that although routine patching is safe r than routine primary closure after carotid endarterectomy (CEA), there is no systematic evidence that patch type influences outcome. However, most s urgeons still believe that prosthetic patches are probably more thrombogeni c than vein patches. This study tested the hypothesis that there was no dif ference in thrombogenicity between the different patch types. Methods: A total of 274 patients undergoing 276 CEAs were randomized to eit her Dacron-patch closure (n = 137) or vein-patch closure (n = 139). All pat ients with an accessible cranial window were monitored for 3 hours postoper atively with transcranial Doppler scanning (TCD). The number of emboli and rate of embolization were quantified with the requirement for selective dex tran therapy to control high rates of postoperative embolization. All patie nts were assessed postoperatively and again at 30 days by a neurologist, an d all patients underwent a duplex examination at 30 days. Results: The 30-day death/any stroke rate was 2.2% for patients in the Dacr on-patch group and 3.6% for patients in the vein-patch group (P = .72). Pat ients in the Dacron-patch group had a higher incidence of postoperative emb oli (median, 5; interquartile range, 0-10.5) than patients in the vein-patc h group (median, 3; interquartile range, 1-17; P = .028). However, the inci dence of detecting more than 50 emboli was virtually identical, and patch t ype had no effect on the incidence of high-rate, sustained embolization tha t required dextran therapy (5.3% for Dacron, 3.7% for vein). No patient had a carotid thrombosis at 30 days. Conclusion: Sustained, high-rate embolization, previously shown to be highl y predictive of progression to carotid thrombosis, appears to be patient de pendent, rather than related to patch type.