Eversion versus conventional carotid endarterectomy for preventing stroke

There is not enough evidence to decide the best way to do the operation of carotid endarterectomy (CEA) to prevent stroke. The carotid artery is one of the main arteries in the neck supplying blood to the brain. A blockage in the artery can cause a stroke (a sudden catastrophe in the brain either because an artery to the brain blocks, or because an artery in or on the brain ruptures and bleeds). CEA involves two different methods to clear the artery. This is done by either eversion (oblique division of the internal carotid artery at its origin, removing the blockage through this access and reimplantation (re-joining) of the vessel at the same original level) or conventional CEA (longitudinal opening of the artery followed by removal of the blockage and suture with or without an enlargement patch). The review found that there was not enough evidence to show either the benefits or adverse effects of these two methods. Eversion CEA may lower the risk of restenosis (renarrowing) of the artery but more research is needed.

Authors' conclusions: 

Eversion CEA may be associated with low risk of arterial occlusion and restenosis. However, numbers are too small to definitively assess benefits or harms. Reduced restenosis rates did not appear to be associated with clinical benefit in terms of reduced stroke risk, either perioperatively or later. Until further evidence is available, the choice of the CEA technique should depend on the experience and familiarity of the individual surgeon.

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Background: 

Carotid endarterectomy (CEA) is conventionally undertaken by a longitudinal arteriotomy. Eversion CEA, which employs a transverse arteriotomy and reimplantation of the carotid artery, is reported to be associated with low perioperative stroke and restenosis rates but an increased risk of complications associated with a distal intimal flap.

Objectives: 

To determine whether eversion CEA was safe and more effective than conventional CEA. The null-hypothesis was that there was no difference between the eversion and the conventional CEA techniques (performed either with primary closure or patch angioplasty).

Search strategy: 

We searched the Cochrane Stroke Group Trials Register (last searched July 2002), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2002, Issue 4), MEDLINE (1966 to December 2002) and EMBASE (1980 to December 2002). In addition, eight surgical journals were handsearched and researchers were contacted to identify additional published and unpublished studies.

Selection criteria: 

All randomised trials comparing eversion to conventional techniques in patients undergoing carotid endarterectomy were examined in this review. Outcomes were stroke and death, carotid restenosis/occlusion, and local complications.

Data collection and analysis: 

Data were extracted independently by two reviewers to assess eligibility and describe trial characteristics, and by one reviewer for meta-analyses. When possible, unpublished data were obtained from investigators.

Main results: 

Five trials were included for a total of 2465 patients and 2589 arteries. Three trials included bilateral carotid endarterectomies. In one trial, arteries rather than patients were randomised so that it was not clear how many patients had been randomised in each group, therefore, information on the risk of stroke and death from this study were considered in a separate analysis. There were no significant differences in the rate of perioperative stroke and/or death (1.7% versus 2.6%, odds ratio (OR) 0.44, 95% confidence interval (CI) 0.10 to 1.82) and stroke during follow up (1.4% versus 1.7%, Peto OR 0.84, 95% CI 0.43 to 1.64) between eversion and conventional CEA techniques. Eversion CEA was associated with a significantly lower rate of restenosis > 50% during follow up (2.5% versus 5.2%, Peto OR 0.48, 95% CI 0.32 to 0.72). However, there was no evidence that the eversion technique for CEA was associated with a lower rate of neurological events when compared to conventional CEA. There were no statistically significant differences in local complications between the eversion and conventional group. No data were available to define the cost-benefit of eversion CEA technique.

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