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Patch angioplasty versus primary closure for carotid endarterectomyBond R, Rerkasem K, AbuRahma AF, Naylor AR, Rothwell PM
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SummaryEvidence now suggests a benefit from using routine patch angioplasty during carotid endarterectomy.About 20% of strokes result from narrowing of the carotid artery (the main artery supplying blood to the brain). Carotid endarterectomy is an operation that involves opening the carotid artery to remove this narrowing and therefore, reduce the risk of stroke. However, there is a 2% to 10% risk of the operation itself causing a stroke. Some surgeons advocate the incorporation of a patch made out of either synthetic material or the patients own vein, into the arterial closure. This may help to reduce the risk of the artery being narrowed during suture placement and may, therefore, reduce the risk of recurrent blockage and consequent stroke and/or death. However, use of a patch may increase surgical difficulty and operation length. Furthermore, thin walled vein patches may rupture with potentially fatal consequences and synthetic materials are vulnerable to infection.
This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2008 Issue 3, Copyright © 2008 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).
This version first published online:
April 25. 1995 AbstractBackgroundCarotid patch angioplasty (with either a venous or a synthetic patch) may reduce the risk of carotid artery restenosis and subsequent ischaemic stroke. ObjectivesThe objective of this review was to assess the safety and efficacy of routine or selective carotid patch angioplasty compared to carotid endarterectomy with primary closure. Search strategyWe searched the Cochrane Stroke Group Trials Register (last searched November 2002). In addition, we searched the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), MEDLINE (1966 to December 2001), EMBASE (1980 to December 2001) and Index to Scientific and Technical Proceedings (1980 to 2001). We also handsearched eight journals and five conference proceedings. Reference lists were checked and we contacted experts in the field to identify further published and unpublished studies. Selection criteriaRandomised and quasi-randomised trials comparing carotid patch angioplasty with primary closure in any patients undergoing carotid endarterectomy. Data collection and analysisTwo reviewers independently assessed eligibility, trial quality and extracted the data. Main resultsThe previous review included six trials involving 794 patients undergoing 882 operations. Since the last review only one study of adequate quality to be included has been reported. This added 399 operations randomised to either primary closure, vein patch or synthetic patch groups resulting in 1127 patients undergoing 1307 operations being available for analysis. The quality of trials was generally poor. Follow-up varied from hospital discharge to five years. Carotid patch angioplasty was associated with a reduction in the risk of stroke of any type (OR = 0.33, p = 0.004), ipsilateral stroke (OR = 0.31, p = 0.0008), and stroke or death, during the perioperative period (OR = 0.39, p = 0.007) and long term follow-up (OR = 0.59, p = 0.004). It was also associated with a reduced risk of perioperative arterial occlusion (odds ratio 0.15, 95% confidence interval 0.06 to 0.37 p = 0.00004), and decreased restenosis during long-term follow-up in five trials, (odds ratio 0.20, 95% confidence interval 0.13 to 0.29 p < 0.00001). These results are more certain than those of the previous review since the number of operations and events have increased. However, the sample sizes are still relatively small, data were not available from all trials, and there was significant loss to follow-up. Very few arterial complications, including haemorrhage, infection, cranial nerve palsies and pseudo-aneurysm formation were recorded with either patch or primary closure. No significant correlation was found between use of patch angioplasty and the risk of either perioperative or long-term all-cause death rates Authors' conclusionsLimited evidence suggests that carotid patch angioplasty may reduce the risk of perioperative arterial occlusion and restenosis. It would appear to reduce the risk of combined death or stroke and there is a non significant trend towards a reduction in all-cause mortality. |