Restenosis After Carotid Endarterectomy in Patients with Paired Vein and Dacron Patch Reconstruction

Abstract

This is an analysis of restenosis after bilateral carotid endarterectomy (CEA) with saphenous vein patch reconstruction on one side and Dacron patch reconstruction on the other. The possibility that differences in reconstruction geometry between vein and Dacron patched sides effected restenosis outcomes was evaluated as was the value of serial common carotid wall thickness measurements in predicting restenosis.

Between 1990 and 1997, 33 bilateral CEA were performed within one year on 22 men and 11 women using a greater saphenous vein patch on one side and a knitted Dacron patch on the other. Interoperative post-CEA geometry was measured. Follow-up was by duplex scans that included wall thickness measurements in the endarterectomized common carotid bulb.

Over a mean follow-up of 43 months 10 (30%) Dacron patched and one (3%) vein patched CEA developed?25% restenosis (p=0.001), seven (21%) Dacron patched and no vein patched CEA developed >50% restenosis (p=0.01) and four (12%) Dacron patched and no vein patched CEA developed >70% restenosis (p =0.1 1). The Kaplan-Meier cumulative >25% restenosis rates for Dacron and vein patched CEA were 22% and 0% at 2 years and 41% and 5% at 5 years respectively (p=0.002). The cumulative >50% restenosis rates for Dacron and vein patched CEA were 16% and 0% at 2 years and 34% and 0% at 5 years respectively (p = 0.003). The cumulative?70% restenosis rates for Dacron and vein patched CEA were 8% and 0% at 2 years and 20% and 0% at 5 years respectively (p = 0.02). For both patients with and without recurrent stenosis the mean within patient between sides differences of the diameters of the internal carotid, internal carotid bulb, common carotid bulb, and common carotid arteries and the lengths of the internal carotid and total patch segments were not significantly different and all were less than 5%. Common carotid bulb wall thickness measured at the time of identification of the nine unilateral Dacron patched CEA restenosis was 1.5 ±0.5 mm compared to 1.4 +0.4 mm (m ± 1 SD) for the contralateral vein patched CEA (p = 0.45 by paired t test). Dacron patched CEA have a significantly higher incidence of mild, moderate and severe restenosis than do saphenous vein patched CEA independent of systemic risk factors. The within patient equality of Dacron and vein patched carotid reconstruction geometry in patients with unilateral restenosis indicates that patch material is the major local risk factor, not adverse hemodynamics produced by variance in geometry. Common carotid bulb wall thickness measurements after CEA are not predictors or indicators of recurrent stenosis.

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References

1. Hertzer NR , O'Hara PH , Mascha EJ , et al: Early outcome assessment for 2228 consecutive carotid endarterectomy procedures: The Cleveland Clinic experience from 1989 to 1995. J Vasc Surg 26:1-10, 1997.

2. Archie JP : Carotid endarterectomy outcome with vein or Dacron patch angioplasty and internal carotid shortening. J Vasc Surg 29:654-664, 1999.

3. Archie JP : A 15-year experience with carotid endarterectomy following a formal operative protocol requiring highly frequent patch angioplasty. J Vasc Surg 31:724-735, 2000.

4. Archie JP : Carotid patching: What is the optimal patch material. In: Goldstone (ed): Perspectives in Vascular Surgery, vol 10. New York, Thieme, 1999, pp 105-112.

5. Archie JP : Carotid endarterectomy outcomes. In: Whittemore AD (ed): Advances in Vascular Surgery, vol VII. St. Louis: Mosby, 1999, pp 1-22.

6. Archie JP : Wall thickness after carotid endarterectomy in patients with paired vein and Dacron patch reconstruction. J Vasc Surg 25:554-560, 1997.

7. Archie JP : Geometric dimension changes with carotid endarterectomy reconstruction. J Vasc Surg 25:488-498, 1997.

8. Archie JP : The endarterectomy produced common carotid artery step: A harbinger of early emboli and late restenosis. J Vasc Surg 23:932-939, 1996.

9. Archie JP : Patching with carotid endarterectomy: When to do it and what to use. Semin Vasc Surg 11:24-29, 1998.

10.

10. Tretter JF , Hertzer NR , Maseja EJ , et al: Revioperative risk and late outcome of non-elective carotid endarterectomy. J Vasc Surg 30:618-631, 1999.

11.

11. Archie JP : Early and late geometric changes after carotid endarterectomy patch reconstruction. J Vasc Surg 14:258-266, 1991.

12.

12. Abu Rahma AF , Robinson PA , Saiedy S , et al: Prospective randomized trial of bilateral carotid endarterectomies. Stroke 30:1185-1189, 1999.

13.

13. Fabiana J , Julia P , Chemia E , et al: Is the incidence of recurrent carotid stenosis influenced by the choice of the surgical technique? Carotid endarterectomy versus saphenous vein bypass. J Vasc Surg 20:821-825, 1994.

14.

14. Rossi PJ , Valentine RJ , Myers SI , et al: The durability of bilateral carotid endarterectomy. Ann Vasc Surg 9:16-20, 1995.

15.

15. Delcker A , Diener HC , Wilhelm H : Influence of vascular risk factors for atherosclerotic carotid artery plaque progression. Stroke 26:2016-2022, 1995.

16.

16. Howard G . Barke GL , Evans GW , et al: Relations of intimal-medial thickness among sites within the carotid artery as evaluated by B-mode ultrasound. Stroke 25:1581-1587, 1994.

17.

17. Espeland MA , Tang R , Terry JG , et al: Association of risk factors with segment-specific intimal-medial thickness of the extracranial carotid artery. Stroke 30:1047-1055, 1999.

18.

18. Flis V , Miskic K , Pavlovic M : Is there a correlation between intima-media thickness of the common carotid artery and recurrent stenosis after carotid Dacron patch angioplasty (abstract). Cardiovasc Surg 7:16-17, 1999.