A nationwide cohort study of over 9,000 patients shows that the “controversial” practice of arteriotomy closure for carotid endarterectomy (CEA) is associated with an increased risk of ipsilateral stroke and “should be avoided”. Instead, authors Magnus Jonsson (Karolinska University Hospital, Stockholm, Sweden) and colleagues argue, endarterectomy should be performed with either routine patch closure or using the eversion technique. Despite these findings, the authors underline the fact that primary closure “remains common practice” among some surgeons.
The study—recently published as an Editor’s Choice paper in the European Journal of Vascular and Endovascular Surgery (EJVES)—also shows that the long-term durability of different patch materials is equivalent, and that bovine pericardium and eversion have a lower risk of late infections.
Jonsson et al note in their introduction that current European guidelines recommend both eversion CEA and conventional CEA with routine patch closure, rather than routine primary closure. However, they add, “many surgeons prefer selective patching and there remains much controversy about the relative benefits of the different surgical techniques and patches for CEA”. The aim of the present study was to evaluate the short- and long-term outcomes after CEA based on surgical technique and patch material.
The investigators detail that there are several available patch types on the market at present. “Dacron, vein and polytetrafluoroethylene (PTFE) have been used for a long time,” they state, adding that bovine pericardium has been used in more recent years. “Bovine pericardium may have the advantage of greater resistance to late infections and smaller haematomas than other patch types, but there are few long-term follow-up studies comparing pericardium with other patch materials,” the authors comment.
The researchers conducted a registry-based study on all primary CEAs performed for symptomatic carotid artery stenosis in Sweden from July 2008 to December 2019, which numbered 9,205 in total. This was cross-linked with data from the Swedish stroke registry, Riksstroke, and chart review for evaluation of any events occurring during follow-up, they detail. The primary endpoint was ipsilateral stroke <30 days and secondary endpoints included reoperations due to neck haematoma and <30-day ipsilateral stroke, >30-day ipsilateral stroke, all stroke >30 days and all-cause mortality.
Reporting the results of their study in EJVES, Jonsson and colleagues reveal that 2,495 patients underwent eversion CEA and 6,710 conventional CEA for symptomatic carotid stenosis. They found that the most commonly used patch material was Dacron (n=3,921), followed by PTFE (n=588) and bovine pericardium (n=413).
Furthermore, Jonsson et al relay that a total of 1,788 patients underwent conventional CEA with primary closure, and that 273 patients (3%) had a stroke within 30 days of intervention.
They also share the finding that that primary closure was associated with an increased risk of ipsilateral stroke and stroke or death within 30 days: odds ratio 1.7 (95% confidence interval [CI] 1.2–2.4, p=0.002); and 1.5 (95% CI 1.2–2), respectively. During follow-up, which was a median of 4.2 years, the investigators report that 592 patients had any form of stroke and 1,492 died. “There was no significant difference in long-term risk of ipsilateral stroke, all stroke or death depending on surgical technique or patch material,” the authors communicate.
“There was an increased risk of ipsilateral stroke <30 days in patients operated on with primary closure compared with eversion CEA and patch angioplasty,” Jonsson and colleagues summarise in their conclusion, adding that there was no difference between primary closure, different patch types or eversion after the perioperative phase.
Strengths and weaknesses
In the discussion of their findings, the authors stress that the results of their study “should be interpreted within the context of the strengths and limitations associated with retrospective analysis of prospectively collected registry data”. Focusing first on the latter, they note that “the high validity” of the Swedevasc registry—with its almost 100% coverage for all carotid procedures performed in Sweden—and the possibility for cross linkage of data based on unique personal identifiers to assess long-term survival and stroke outcome “result in high generalisability and low loss to follow-up in this study”.
On the other hand, given the study assessed carotid procedures performed over a 10-year period, Jonsson and colleagues acknowledge that “changes in practice over time may be a confounder affecting results for factors not captured by the registry”. The authors elaborate that this may include changes in medical management of patients prior to surgery—including preoperative thrombolysis or antiplatelet therapy—as well as changes in periprocedural routines, such as use of different techniques for cerebral monitoring during carotid surgery.
In addition, the researchers recognise that the Swedevasc registry did not include data on arteriotomy length, width of internal carotid artery, type of anaesthesia and intracerebral vessel, and as a result, “these variables were not corrected for”.
Primary closure “remains common practice” by some
Considering the wider importance of their research, the authors write that their study “underlines the variation in surgical techniques used for CEA in Sweden,” underscoring the fact that up to 20% are operated on with primary closure without patch.
Jonsson et al reiterate in their conclusion that, due to its association with an increased risk of postprocedural stroke, the technique “should not be used”. In addition, they note the current report underlines the fact that selective primary closure “remains common practice” by some surgeons, and stress that “further educational efforts to move towards routine patch closure or eversion endarterectomy among all carotid surgeons are warranted”.