Durability of eversion carotid endarterectomy: Comparison with primary closure and carotid patch angioplasty

Objectives: Despite numerous studies in which various methods for arterioto my closure after carotid endarterectomy (CEA) have been addressed, the opti mum surgical technique to reduce complications and late carotid restenosis has yet to be firmly established. The purpose of this study was to prospect ively compare the results of the eversion CEA technique with those of conve ntional CEA with either primary closure or carotid patch angioplasty, and t o determine under clinical conditions whether eversion CEA influences the r esults and restenosis rate. Patients and Methods: Over a 3-year period, 322 CEAs performed on 296 conse cutive patients were concurrently evaluated. This study included 118 eversi on CEAs, 97 CEAs with primary closure, and 107 CEAs with patch angioplasty. There were no differences in demographics, in surgical indications, or in the severity of carotid disease (not significant [NS]). The choice of CEA t echnique was not randomized because of technical considerations and surgeon preference. After entry into the protocol, no patients were excluded or wi thdrawn. Carotid restenosis was defined as a >60% lumen reduction at the CE A site with established duplex ultrasonography criteria. Results. The mean operative time for eversion CEA was 31 minutes, for CEA-p rimary closure it was 39 minutes, and for CEA-patch angioplasty it was 46 m inutes (P<.01). The operative mortality rate for eversion CEA was 0.8% (1 p atient), for CEA-primary closure it was 1.0% (1 patient), and for CEA-patch angioplasty it was 2.8% (3 patients) (NS). The postoperative stroke rate w as 0.8% after eversion CEA, 1.0% after CEA-primary closure, and 2.8% after CEA-patch angioplasty (NS). The combined stroke and death rate in each grou p was thus 0.8% for eversion CEA (I stroke-death), 1% for CEA with primary closure (1 stroke-death), and 5% for CEA with patch angioplasty (1 stroke-d eath, 2 fatal myocardial infarctions, and 2 nonfatal strokes) (NS). Transie nt ischemic attacks occurred in 2.5% after eversion CEA, in 5.2% after CEA- primary closure, and in 2.9% with CEA-patch angioplasty (NS). The mean clin ical follow-up for all three groups was 23 months (range, 6-42 months) (NS) . The restenosis rate was 1.7% after eversion CEA, 9.3% after CEA-primary c losure, and 6.5% after CEA-patch angioplasty (P<.05). Conclusions: This prospective, nonrandomized clinical study indicates that eversion CEA is an effective surgical option comparable to conventional CEA with either primary arteriotomy closure or carotid patch angioplasty. No d ifferences were found between eversion CEA and these more widely accepted C EA closure techniques with respect to operative morbidity and mortality. Th ese data indicate, however, that eversion CEA has a lower restenosis rate t han conventional CEA closure techniques and thus superior long-term durabil ity.